Surg Endosc (2016) 30:S325S500

DOI 10.1007/s00464-016-4771-7

and Other Interventional Techniques

2016 Scientific Session of the Society of American Gastrointestinal

and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA,
1619 March 2016
Poster Presentations

 Springer Science+Business Media New York 2016

P034

P035

The Physiological Assessment to Burden on the Surgeon

in Laparoscopic Surgery Using the 128 Channels EEG

Biomechanical Comparison of the Immediate Fixation Strength

of Non-Traumatic Mesh Fixation Methods: LifemeshTM,
TisseelTM, and ProgripTM

Hisae Aoki, MD1, Toshiyuki Mori, MD, PhD2, Hiromasa Yamashita,

PhD3, Toshio Chiba, MD, PhD3, Akio Mori, PhD4, 1Department
of Surgery, Sanraku Hospital, 2Department of Surgery, Kyorin
University, 3University Research Center (URC), Nihon University,
4
College of Humanities and Sciences, Nihon University
Introduction: The laparoscopic surgery has been evolved by development of the various
laparoscopic surgical systems, for example, the robotic surgical system or the 3-dimension
laparoscopic surgery system. In addition, the laparoscopic instrument such as forceps and
energy devices has been progressing developed. As a result, the evaluation of their usability
should be required. In general 3D camera system has believed to be better than 2D camera
system, however there is no report of proving advantage of the 3D camera by physiological
assessment recoding during operating tasks. Multi-channel Electroencephalogram(EEG) is
a well-known tool to assess the brain activity during tasks, and the beta band pattern
changes in accordance to the brain activity We used the 128 channel EEG to evaluate the
surgeons brain activity in laparoscopic surgery.
Method: The eight surgeons performed standardized skill tasks(Space pointing task
(SPT), Move the ring and Ligation) in the training box. In our study, 128 channel
electroencephalograms were used. Continuous EEG was recorded with a 128 channel EGI
(Electrical Geodesics Inc.). The electroencephalogram was measured continuously while
performing the tasks. After recording, these data were passed through a digital low pass
filter (30 Hz) and a digital high pass filter (3 Hz) to investigate alpha beta and theta band
patterns during tasks. Each band pattern, alpha(813Hz), beta(1325Hz) and theta(48Hz)
were analyzed. The each band activity was expressed as a percentage of the total power in
each segment as 2D topography.
Result: There was no significant difference of beta band patterns between using 2D camera
and 3D camera. In space pointing task, there was no significant difference of beta band
patterns between novice group and expert group. However in performing the Ligation
and Move the ring, significant differences of the beta band pattern between novice group
and expert group were noted.
Conclusion: The 128 channels EEG can be the physiological evaluation to burden on the
surgeons. When the new device is used in laparoscopic surgery, it might be possible to
prove usability with beta band patterns using the 128 channels EEG. And the assessment on
laparoscopic training progress might be possible.

Charles P Shahan, MD1, Nathaniel Stoikes, MD1, Esra Roan, PhD2,

James Tatum, BS2, David Webb, MD1, Guy R Voeller, MD1,
1
University of Tennessee Health Science Center, 2University
of Memphis
Background: LifeMeshTM is a novel self-fixating mesh adhesive technology where largepore, lightweight polypropylene mesh is embedded in a dry matrix of porcine gelatin and
microbial transglutaminase enzyme. Non-traumatic mesh fixation is becoming more widely
accepted, however little is known about the immediate fixation strength of these techniques.
The purpose of this study was to compare the immediate strength of fixation for LifeMeshTM, ProGripTM, and TisseelTM.
Methods: 7 Mongrel swine underwent implantation of two 4x7cm pieces of either LifemeshTM, ProGripTM, or polypropylene mesh fixated with 2mL of TisseelTM. 10 minutes
after application, the samples were excised with the abdominal wall and stored for
immediate biomechanical testing. The samples underwent lap shear testing to determine the
immediate fixation strength of these three technologies.
Results: ProGripTM demonstrated mean fixation strength of 1.3 N/cm ( STE 0.2). Mean
fixation for mesh fixated with TisseelTM was 2.6 N/cm ( STE 0.5). LifeMeshTM samples
had mean fixation strength of 8.0 N/cm ( STE 2.1). Analysis of variance testing showed
that immediate fixation strength of LifeMeshTM was significantly greater than that of either
ProGripTM or TisseelTM (p=0.0004). ProGripTM and TisseelTM were not significantly different from each other (p=0.06).
Conclusions: Immediate strength of mesh fixation is an undescribed factor in hernia repair,
but could have significant implications for early recurrence and mesh contraction. While
further investigation is needed to define adequate interface strength, this comparison of nontraumatic mesh fixation methods shows that the novel LifeMeshTM technology exhibits
greater strength than other non-traumatic fixation techniques.

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P036

P038

High Resolution Manometry - An Underappreciated Tool

for Examination of Dysphagia in a Surgical Setting

Markedly Elevated Levels of Vegf, Ang-2, and MMP-2 in Wound

Fluid After Colorectal Resection Are Likely Responsible
for Elevated Plasma Levels of These Proteins During the First
Postoperative Month Preliminary Results

Jonas S Jensen, MD, Jan M Krzak, MD, Lars Stig Jorgensen, MD,
Lillebaelt Hospital, Kolding, Denmark
Introduction: Examination of dysphagia in Danish surgical departments, rely primarily on upper gastrointestinal
endoscopy. When no visible or histological cause can be detected, esophageal motility disorders are important
differential diagnosis. In examining these disorders and in evaluating gastroesophageal reflux disorder (GERD), High
Resolution Esophageal Manometry (HRM), provide valuable insights.
The purpose of this study was to examine referrals and final diagnosis from HRM in a surgical center specializing in
esophageal disorders.
Methods and Procedures: All patients referred to HRM at our surgical center were included in the study and HRM
was performed from September 2013 to June 2015. All patients had previously undergone upper gastrointestinal
endoscopy at our center or the referring department. All procedures were performed using InSIGHTTM HRiM and
accompanying software (Sandhill Scientific, Colorado, USA) and graded according to the Chicago-classification.
Referring department, referral-diagnosis, demographics and final HRM-diagnosis were prospectively collected and
analyzed.
Results: 438 patients were referred to HRM, primarily from our own department (N=350, 79,9%), other departments
in our hospital (N=12 2,7%), private practice (N=20, 4,6%) and departments at other hospitals (N=56 12,8%).
Of the 390 procedures performed, the referral-diagnosis was motility disorder (n=161, 41,3%) and GERD (n=229,
58,7%). The mean age was 50,417,0 years (rage 1686 years) with 58,5% female and 41,5% male. There were no
significant differences in age or sex when comparing the two groups.
Pathological findings were present in 197 cases. There was no difference in frequency of pathological findings
stratified for referral-diagnosis (p=0.11). Patients referred with suspicion of motility disorder had a significantly higher
frequency of abnormal bolus transit (p=0.02), achalasia (p\0.01) as well as EGJ-outlet obstruction and pseudo
achalasia (p\0.01). Patients referred as part of investigation of GERD, had a significantly higher frequency of weak/
ineffective motility (p=0.02). There was no difference in frequency of nutcracker/jackhammer esophagus between the
two groups (p=0.035)
At our surgical center, the rate of HRM per upper gastrointestinal endoscopy was 4,4% based on 8031 endoscopies. A
similar surgical centre in our area had, based on referral to our center, a HRM to endoscopy rate of 0.1% based on
10419 endoscopies.
Conclusion: HRM is an important diagnostic tool and supplements upper gastrointestinal endoscopy in examination of
dysphagia as well as GERD, with significant differences in patterns of motility disorders. Knowledge and availability
of HRM increases use at a surgical center, yielding better diagnostics of patients with suspected motility disorders.

P037
Compliance of the Abdominal Wall During Laparoscopic
Insufflation
Chuck Becker, MEM1, Margaret Plymale, MSN, RN2, John
Wennergren, MD2, Crystal Totten2, Kyle Stigall1, J Scott Roth, MD2,
1
University of Kentucky College of Medicine, 2University
of Kentucky Department of Surgery
Introduction: To provide working space between the internal organs and abdominal wall, insufflation with carbon
dioxide is a common practice in laparoscopic surgeries. An insufflation pressure of 15mmHg is considered to be safe
in patients, but any amount of insufflation has peri-operative and post-operative cardiopulmonary and renal effects. As
a composition of viscoelastic materials, the abdominal wall should distend in a predictable manner given the pressure
of the pneumoperitoneum underneath during insufflation. The purpose of this study is to elucidate the relationship
between degree of abdominal distention and the insufflation pressure, with the goal of determining which patients
abdomens may distend sufficiently without requiring 15mmHg pneumoperitoneum.
Methods: A prospective, IRB-approved study was conducted to video record the abdomens of patients undergoing
insufflation prior to a laparoscopic surgery. Photo samples were taken every 5 seconds, and the strain of the patients
abdomen in the sagittal plane could be determined, as well as the insufflator pressure (stress) at bedside. Patients were
insufflated to 15mmHg. The relationship between the stress and strain was determined in each sample, and a compliance of the patients abdominal wall was calculated. In addition, patients enrolled had prior, previously indicated
abdominal CTs, which were used to calculate body parameters, such as abdominal fat thickness and rectus muscle
thickness. Correlations between abdominal wall compliances and adipose and muscle content were determined.
Results: Twelve patients studied were undergoing foregut laparoscopic procedures, whereas 9 were undergoing
ventral wall hernia repairs. Of patients studied without abdominal wall hernias (i.e., a structurally-intact abdominal
wall), the relative proportion of muscle in the abdominal wall had an inverse logarithmic relationship with abdominal
wall compliance (R2 = 0.66, p\0.05 given 3 degrees of freedom). Conversely, data is trending that an increasing
proportion, as well as increasing absolute amounts of adipose tissue in the abdominal wall, produces a direct logarithmic relationship with abdominal wall compliance (p=0.1). No change in compliance between patients with
abdominal wall hernias and without abdominal wall hernias was found.
Conclusion: The procedural standard for insufflation pressure during laparoscopic surgeries has been 15mmHg. As the
abdominal walls of patients contain different amounts of adipose and muscle tissue, not all patients need the same
insufflation pressure to obtain the same degree of abdominal distention. Thus, it could be possible to tailor the
insufflation pressure used for patients with lower relative muscle mass, or who may be more susceptible to the side
effects of laparoscopic insufflation.

123

Hmc Shantha Kumara, PhD1, Hiromichi Miyagaki, MdPhD2, Charles

Petrick, BS1, Xiaohong Yan, PhD1, Linda Njoh, PhD1, Vesna Cekic,
RN1, Nipa D Gandhi, MD1, Richard L Whelan, MD1, 1Department
of Surgery, Mount Sinai Roosvelt Hospital, New York, USA,
2
Department of Gastroenterological surgery,Osaka
University,Osaka,Japan
Introduction: Persistently elevated plasma levels of proangiogenic proteins including VEGF, Angiopoietin 2 (Ang2) and
Matrix Metalloproteinase 2 (MMP2) have been noted for 35 weeks after colorectal cancer (CRC) resection. Whereas
increases early after surgery may be due to the brief acute inflammatory response, the origin of the week 25 elevations is
uncertain. We hypothesize that wounds are a major source since angiogenesis plays a critical role in wound healing. This
studys purpose is to determine the levels of the above 3 proteins in fluid from intra-abdominal wounds taken during the 1st
month after CRC resection and compare them to previously determined postoperative plasma levels of the same proteins.
Method: The study population was CRC patients who agreed to enter an IRB approved wound fluid study. Wound
fluid samples (WFS) collected via Jackson Pratt drains on postoperative day (POD) 1, 3, and a variety of later time
points were centrifuged and stored at -80C. Late samples (POD 720) were bundled into 7 day blocks and considered
as single time points. VEGF, ANG2 and MMP2 levels were determined in duplicate via ELISA and reported as
mean SD. The paired t-test was used for statistical analysis (significance p\0.05).
Results: Nine cancer patients were studied (8 rectal, 1 colon; mean age 65.3 2.3 years; surgical methods used:
laparoscopic-assisted, 4; hand-assisted laparoscopic, 1; and lap. converted to open, 4 (mean incision length for lap &
hand, 6.44.3; for open 238.2). The mean length of stay was 7.8 3.5 days. The cancer stage breakdown was; Stage
1, 25%, Stage 2, 38%, stage 3, 25% and stage 4, 12%. The range of wound levels noted after surgery were: VEGF,
17627586 pg/ml; ANG-2, 908217393 pg/ml; and MMP-2, 5791216 ng/ml. Previously determined plasma levels in
similar CRC patients ranged from: VEGF, 164371 pg/ml; ANG-2, 26714095 pg/ml; and MMP-2, 177262 ng/ml.
Further, the POD 713 wound levels of VEGF, ANG-2 and MMP-2 were higher than the POD1 results.
Conclusions: When compared to previously determined postop plasma levels, wound levels of VEGF, ANG-2, and
MMP-2 were 6 to 13 times higher. Also, wound levels continued to rise and peaked during the second (ANG-2) and
third weeks (VEGF, MMP-2) after surgery. These results suggest that the very high wound levels of these proangiogenic proteins contribute to the elevated plasma levels noted after surgery. The plasma changes may promote the
growth of residual tumor deposits after surgery.

P039
Gut Bacterial Translocation is Correlated with Stimulated Tlr4
Signaling Pathways in a Rat Model of Abdominal Compartment
Syndrome
Adam Strier, MD3, Ibrahim Matter, MD3, Izhak Srugo, MD3, Nir
Bitterman, MD3, Gideon Sroka, MD3, Tatiana Dorfman, MD1, Yulia
Pollak, MD2, Igor Sukhotnik, MD3, 3Bnai Zion Medical Center,
Haifa, ISRAEL, 1Rambam Healthcare Campus, Haifa, ISRAEL,
2
Technion-Israel Institute of Technology, Haifa, Israel
Objective: Pneumoperitoneum is the basic step in every laparoscopic procedure, and has been established in previous
studies as a trigger for bacterial translocation. Toll-like receptor 4 (TLR-4) is responsible for the recognition of
bacterial endotoxin or lipopolysaccharide (LPS) and for initiation of gram-negative bacillary septic shock syndrome.
Our objective was to determine the effects of elevated intaabdominal pressure (IAP) on bacterial translocation and
TLR-4 signaling in a rat model of abdominal compartment syndrome (ACS).
Methods: Male Sprague-Dawley rats were randomly assigned to one of two experimental groups: control animals
(CONTR) and ACS animals that were subjected to a 15 mmHg pressure pneumoperitoneum for 30 minutes. Rats were
sacrificed 24 hours later. Bacterial translocation (BT) to mesenteric lymph nodes, liver, portal blood and peripheral
blood were determined at sacrifice. TLR4-related gene and protein (TLR-4, myeloid differentiation factor 88 (Myd88)
and TNF-a receptor-associated factor 6 (TRAF6)) expression were determined using Real Time PCR, Western
blotting and immunohistochemistry.
Results: About 30 % of control rats exhibited BT toward the mesenteric the lymph nodes (level I), 20% toward the
liver and portal blood (level II). ACS rats demonstrated a 80% BT to lymph nodes (Level I) and a 40% BT to liver
portal flow (Level II). Elevated BT was accompanied by a significant increase in TLR-4 staining in jejunum (51%) and
ileum (35.9%), as well as in a number of TRAF6 positive cells in jejunum (2.1%) and ileum (24%) compared to
control animals. ACS rats demonstrated a significant increase in TLR4 and MYD88 protein levels compared to control
animals.
Conclusions: 24 hours after induction of abdominal compartment in a rat model, elevated bacterial translocation rates
were accompanied by a stimulation of TLR4-signaling in intestinal mucosa.

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P040

P042

The Validity for the Laparoscopic Colorectal Surgery Using

the Absorbable Adhesion Barrier Made of Oxidized Regenerated
Cellulose

Long Term Results of Laparoscopic Surgery Following Long

Course Chemoradiotherapy for Locally Advanced Rectal Cancer

Masanori Naito, MD, PhD, Masahiko Watanabe, MD, PhD, Ken

Kojo, MD, Takahiro Yamanashi, MD, PhD, Naoto Ogura, MD,
Hirohisa Miura, MD, Atsuko Tsutsui, MD, Takeo Sato, MD, PhD,
Takatoshi Nakamura, MD, PhD, Kitasato University, Department
of Surgery
Background: Clinical use of absorbable adhesion barrier made of oxidized regenerated cellulose
(INTERCEED) is reported in the field of obstetrics and gynecology to prevent adhesion ileus. Meanwhile, in
the field of gastrointestinal surgery, sodium-hyaluronate / carboxymethylcellulose (Seprafilm) is reported to
be used as an absorbable adhesion barrier. However, Seprafilm is difficult to use with the trocars in
laparoscopic surgery.
Methods: We analyzed 50 patients who were performed laparoscopic colorectal surgery using INTERCEED from 2013 to 2014 in Kitasato University. We investigated maneuverability of INTERCEED for
laparoscopic surgery. We used the VAS (Visual Analog Scale) for evaluation.

Results: We investigated the relationship between the length of the small incision and the
ease of trimming, the ease of intraabdominal delivery, the ease of extent in surgical site and
the stick to surgical site for the evaluation of maneuverability. Results showed that the
mean was 9 cm or greater by VAS for all investigation factors.
Conclusion: We showed that INTERCEED has excellent maneuverability in laparoscopic surgery which the
operating space is narrow. INTERCEED is an extremely valuable medical resource, and we think that the
use of this material will be able to contribute extensively to the prevention of postoperative adhesions.

Omer Jalil, Dr, Thanjakumar Arulampalam, Dr, Bruce Sizer, Dr,

Darren Boone, Dr, Roger Motson, Professor, ICENI Centre
Objectives: The treatment of locally advanced rectal cancer (LARC) has undergone significant change over
the last 20 years. Although surgical resection remains the mainstay of treatment, neoadjuvant radiotherapy
(CRT) may render LARC operable and enable sphincter preservation. In parallel, laparoscopic rectal cancer
surgery (LRS) has developed so that it is feasible to utilize this technique with its proven short term benefits
for pelvic dissection. This study assesses the outcome of patients who have undergone laparoscopic surgery
following CRT for LARC.
Methods: Between January 2004 and June 2012 consecutive patients undergoing LRS following CRT for
LARC at our institution were entered into a prospective database. All surgery was performed in a specialist
laparoscopic surgical unit with surgery carried out by trained attending surgeons. Patients underwent
standard CRT if poor risk features were identified on MRI and the decision to treat was ratified by the
colorectal multidisciplinary team (MDT). All MRI protocols were standardized. CRT consisted of oral
Tegafururacil (UFT) and two-phase, conformal, external beam radiotherapy of 4550.4 Gy in 2528
fractions over 5 weeks. Clinical assessment was carried out twice weekly from 4 weeks post completion of
CRT and MRI was repeated at 67 weeks and 10 weeks with the median time to surgery being 12 weeks.
Patients underwent standard technique laparoscopic resection of the rectum. Data was collected on demographics, treatment regime, ASA grade, BMI, operative data, length of stay, complications defined by
Dindo, mortality and overall and disease free survival.
Results: 112 patients underwent CRT of whom 103 underwent surgical resection. Median follow up was 42
months. Laparoscopic TME was carried in 89 (86.4%) patients with 11 (12.4%) conversions to open
surgery. 11 patients underwent open surgery and 3 patients underwent local resection. 30 day post operative
mortality occurred in 3 (2.9%) patients. Major complications occurred in 33% patients and minor complications in 13% patients. Anastomotic leaks occurred in 14/59 (24%) patients of whom 7 patients required
surgical intervention. R0 resection was achieved in 92% of patients and complete pathological response was
seen in 21 (19%). The local recurrence rate was 11%. The overall, disease free and relapse free survival
were 57%, 49% and 67%.
Discussion: This study demonstrates the feasibility and safety of the laparoscopic approach for surgical resection
of rectal cancer following CRT in a specialist unit with structured training. Delaying surgery following CRT does
not seem to have an adverse oncological outcome.

P041

P043

Simultaneous Laparoscopic Surgery for Advanced Gastric

and Colon Cancer

Comparison Between Laparoscopic Surgery and Open Surgery

for Patients with Locally Advanced Colon Cancer by Propensity
Score Matching

Hanae Matsumoto, Takashi Mitsui, Michiya Bando, Yoshinori

Oikawa, Noriyasu Tamura, Kawakita general hospital
Background: The safeness of simultaneous laparoscopic surgery for synchronous advanced cancer of
stomach and colon has not been fully verified. Well report our experience of simultaneous laparoscopic
surgery for total gastrectomy and left colorectal resection.
Case Presentation: A 71-year-old man was admitted to our hospital for his stomachache. On Computed
Tomography (CT), we found that his colon and small bowel were filled with intestinal liquid due to
obstruction caused by descending colon cancer. We inserted a stent to alleviate the obstruction, which took
ten days. Before the operation for the colon, we did gastroscopy and found gastric cancer, 2 x 2 cm in size,
4cm from the esophagus-gastric junction. It was confirmed as poorly differentiated adenocarcinoma by
biopsy. No lymph node swelling or metastatic lesion was found on CT. Our diagnosis: gastric cancer
cStage1A (T1 N0 M0) and colon cancer cStage2 (T4a N0 M0).
Operation and Outcome: The trocar positions are shown in the following Fig. 1.
Umbilical port (No.1)- we inserted a laparoscope from this port and performed extracorporeal anastomosis
on colorectal resection. We used 12mm trocars (Nos.2, 4, and 6) and 5mm trocars (Nos.3, 5, and 7). For
gastric cancer, we performed laparoscopic total gastrectomy with D1+ lymph node dissection and Roux-enY reconstruction under Japanese guidelines. Simultaneously, for colon cancer, we performed laparoscopic
left colorectal resection with D3 lymph node dissection and functional end-to-end anastomosis. There were
no serious troubles during the operation: the operating time was 586 minutes and the estimated blood loss
200ml. On postoperative day (POD) 2, we performed upper gastrointestinal series, and found no leakage
from the esophageal gastrostomy and the small intestinal anastomosis. On the same day, the patient started
to drink water at lunch, and oral liquid diet at supper. He was discharged on POD7. Pathological examination of the stomach showed moderately differentiated adenocarcinoma invading the lamina propria and
that of the colon moderately differentiated adenocarcinoma invading the serosa. Under Japanese guidelines,
our final diagnosis was T1 N0 M0 fStage1A for the stomach cancer and T3 N0 M0 fStage2 for the colon
cancer. Recurrence has not been found for 8months since the operation.
Conclusion: We experienced simultaneous laparoscopic surgery for total gastrectomy and left colorectal
resection with no complication. It will be safe and useful to perform simultaneous laparoscopic surgery for
advanced gastric and colorectal cancer for selective patients.

Shoichi Fujii, PhD1, Takahiro Yagi1, Mitsuo Tsukamoto1, Yoshihisa

Fukushima1, Takuya Akahane1, Ryu Shimada1, Keisuke Nakamura1,
Tamuro Hayama1, Takeshi Tsuchiya1, Keijiro Nozawa1, Keiji
Matsuda1, Hirokazu Suwa2, Atsushi Ishibe2, Jun Watanabe2,
Mitsuyoshi Ota2, Yojiro Hashiguchi, Prof1, 1Teikyo University,
2
Yokohama City University Medical Center
Background: Laparoscopic colectomy (LC) was not able to show non-inferiority in overall survival (OS)
from results of JCOG0404 study that was RCT of LC versus open colectomy (OC) for the advanced colon
cancer. However, 5y-OS was 90% or higher in both arms, and the relapse-free survival (RFS) was also
equal. LC was favorable in the short-term results compared with OC. The transverse and descending colon
were excluded, and participated facilities were limited strictly in JCOG0404.
Purpose: To clarify whether LC is applicable as a standard surgery for patients with advanced colon cancer
by analysis of treatment results
Patients & Methods: The short-term and long-term results were compared between 675 LC and 815 OC to
p-stageII/III of the colon and rectosigmoid cancers that were treated from 2000 to 2014. Because the
indication of LC changed over the years, the backgrounds were matched by propensity score matching. The
variables were as follows: gender, age ([70), ASA (2 or more), history of laparotomy, location (right or
left), pT4, diameter ([50mm), p-Stage, operator (certified surgeon by JSES), and observation time (3 years).
Result: The conversion from LC to OC was 3.9% (26 patients). Each of the 379 patients was extracted by
propensity score matching. There was no difference in both groups backgrounds. In the short-term, the
results of LC were favorable in terms of blood loss (292ml:77), transfusion (9.0%:3.4), all early complications (35.9%:19.5), grade 2B (23.5:10.6), grade 3B (7.4:2.6) and postoperative stay (17days:14), however,
operative time (197min:214) was longer. In the pathologic findings, there were no differences in the number
of dissected lymph nodes (25.1:25.8), proximal margin (107mm:106), distal margin (108mm:101), and the
positive vertical margin (1.1%:1.3). In the long-term, the results of LC were excellent in 5y-OS
(79.4%:87.8). There was no difference in 5y-RFS between both arms (69.6%:74.9). LC was excellent in OS
(94.0%:92.8) of p-stageII in the analysis of each stage. There were no differences in the recurrence
(15.0%:18.7) and the first recurrent organs. Pathological T4 and p-stage III were risk factors in the analysis
of recurrence. The peritoneal recurrences of pT4 were higher in LC than OC (6.3%:16.1).
Conclusion: The short-term results of LC were excellent, and the long-term results were equal to OC. It was
suggested that LC was possible to be regarded as a standard surgery for most patients with advanced colon
cancer. However, it seemed that greater caution was necessary for T4 cases with respect to peritoneal
recurrence.

Fig. 1 .

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Surg Endosc (2016) 30:S325S500

P044

P046

Prophylactic Mesh for Prevention of Parastomal Hernia: A MetaAnalysis of Randomized Controlled Trials

Laparoscopic Lateral Pelvic Lymph Node Dissection for Locally

Advanced Rectal Cancer

Sunil V Patel, MD, Msc1, Sami A Chadi, MD, MSc2, Steve D

Wexner, MD2, 1Kingston General Hospital, 2Cleveland Clinic Florida

Mitsuyoshi Ota, MD, PhD1, Jun Watanabe, MD, PhD2, Atsushi

Ishibe, MD, PhD3, Hirokazu Suwa, MD1, Masashi Momiyama, MD,
PhD3, Yasushi Ichikawa, MD, PhD4, Chikara Kunisaki, MD, PhD1,
Itaru Endo3, 1Gastroenterological Center, Yokohama City University
Medical Center, 2Surgery, Yokosuka Kyosai Hospital, 3Department
of Gastroenterological Surgery, Yokohama City University,
4
Department of Clinical Oncology, Yokohama City University

Introduction: The purpose of this meta-analysis is to determine if prophylactic placement of mesh in those
undergoing stoma creation reduces the odds of developing a parastomal hernia.
Methods and Procedures: A meta-analysis was completed, after searching both EMBASE (1946 2015)
and MEDLINE (1946 2015). Randomized controlled trials were included in our analysis if they assessed
the placement of prophylactic mesh vs. non placement in patients undergoing stoma formation. We included
both biologic and synthetic mesh, as well as any technique for mesh placement (preperitoneal, sublay). The
primary outcome was parastomal hernia formation at [1 year of follow up. Secondary outcomes included
parastomal hernia requiring surgical repair and perioperative complications. Subgroup analyses were
planned to assess the effect of biologic vs. synthetic mesh, mesh position (sublay vs. preperitoneal) and
method of diagnosis of parastomal hernia (clinical vs. imaging). Heterogeneity was explored using the I2
statistic. Risk of bias of included studies was assessed as per the Cochrane Handbook. The quality of
evidence was evaluated using the GRADE criteria.
Results: After title, abstract and full article screening, a total of 7 randomized controlled trials, with 395
participants, fit the inclusion criteria. Included studies had similar patient characteristics between groups.
Four of 7 studies had a high risk of bias, while the other 3 had unclear risk of bias. Two studies used biologic
mesh. Three studies used a preperotineal placement of mesh, while 4 studies used a sublay mesh placement.
The pooled analysis showed a significant decrease in the odds of developing a parastomal hernia in the
prophylactic mesh group (OR 0.19, 95%CI 0.10 0.34, I2 = 47%). There was no evidence that placement of
mesh increased the odds of complications (OR 1.54, 95%CI 0.78 3.05, I2 = 53%) or the odds of patients
requiring surgical intervention (3 Studied, OR 0.76, 95%CI 0.27 2.14, I2 0%). The quality of evidence was
determined to be moderate.
Limitations: Moderate heterogeneity was seen in the assessed primary and secondary outcomes, which
could not be explained through subgroup analysis.
Conclusions: There is moderate quality of evidence to suggest that prophylactic mesh reduces the odds of
parastomal hernia in those requiring a stoma. There is no evidence to suggest that placement of mesh
reduces the odds of surgical repair of parastoma hernia or increases odds of complications.

Purpose: Lateral pelvic node metastases occur in 10 to 20 % of locally advanced rectal cancer. Less
invasive and effective lymph node dissection of lateral pelvic lesion is required when skipping routine
preoperative radiation therapy. We developed the technique for laparoscopic lateral pelvic node dissection
(LLPND) and assessed its feasibility.

Methods: Two areas of lateral pelvic region are dissected. One of which is the area along
the obturator artery running in front of the internal obturator muscle. The other is the area
along the internal iliac artery and its visceral branches which is enveloped in the endopelvic
fascia with pelvic organs and its dominant nerves. To avoid nerve injury, the pelvic plexus
should be separated from the internal iliac artery and its branches.
Results: From April 2012 to March 2015, 52 patients with clinical Stage II/III rectal cancer
underwent total mesorectal excision with LLPND. None of the patients received preoperative
radiation therapy. Forty two of the 52 patients received neoadjuvant chemotherapy. Sphincter
preserving operation was performed in 46 patients (79.3%). Average operation time and blood
loss were 411 minutes and 193ml respectively. Clavien-Dindo Grade 3 or worse morbidity rate
was 5.8% and none of the patients required urinary clean intermittent catheterization or fecal
incontinence. Average number of harvested lymph nodes of lateral pelvic region was 11.6.
Lateral pelvic node metastases existed in 8 (15.4%) patients; 5 in the internal iliac artery and its
visceral brunch area, 1 in internal obturator area and 2 in both areas.
Conclusion: Laparoscopic lateral pelvic node dissection can be performed safely. Together
with neoadjuvant chemotherapy, it may become an effective alternative for radiation
therapy in locally advanced rectal cancer.

P045

P047

Short Term Outcome of the Laparoscopic Colectomy

for Transverse Colon Cancer in a Single Institution

Minimally Invasive Colorectal Resection (MICR) Is Associated

with Elevated Plasma Levels of Matrix Metalloproteinase 2
(MMP2) During the First Month After Surgery Which May
Promote Tumor Growth and Metastasis

Ryuichi Sekine, Showa University Fujigaoka hospital

Background: The role of laparoscopic surgery in the treatment of transverse colon cancer remains controversial in Japan. The aim of the present study is to review the short term outcomes of the laparoscopic
surgery for transverse colon cancer.
Methods: Most cases were advanced cases. Our principle of the procedure is to perform D3 dissection and
complete resection of mesocolon (CRM) for the advanced cases. Thirty-one patients underwent laparoscopic
surgery for transverse colon cancer in our hospital from February 2010 to November 2014. We conducted
partial resection of transverse colon, right hemicolectomy and left hemicolectomy depending on the location
and stage of the tumor. We reviewed short term outcomes including operative time, blood loss, postoperative complication, conversion to open surgery, recurrence after resection.
Results: Patients with transverse colon cancer underwent 22 (70%) partial resection of transvers colon, 6
(20%) right hemicolectomy and 3 (10%) left hemicolectomy. Median operative time was 240 min (125555
min). Median blood loss was 100 mg (5700 mg). Rate of postoperative complications was 12% (lymph
fistula: 10%, ileus: 3%). Conversion rate to open surgery was 3% because of the invasion to duodenum. So
far no recurrence case has been observed.
Conclusion: Laparoscopic resection of transverse colon cancer is technically feasible and not associated
with a significantly higher rate of complications compered with laparoscopic resection for other colon
cancer.

123

Hmc Shantha Kumara, PhD1, Hiromichi Miyagaki, MDPhD2, Charles

Petrick, BS1, Xiaohong Yan, MDPhD1, Linda Njoh, PhD1, Vesna
Cekic, RN1, Nipa D Gandhi, MD1, Richard L Whelan, MD1,
1
Department of Surgery, Mount Sinai Roosvelt Hospital, New York,
USA, 2Department of Gastroenterological surgery,Osaka
University,Osaka,Japan
Introduction: Matrix Metalloproteinase -2(MMP-2) degrades type IV collagen, a major component of
basement membranes. MMP-2 plays important roles in tissue remodeling and wound healing but has also been
implicated in disease processes including cancer. Elevated MMP-2 activity has been linked to a poor prognosis
in lung, breast, prostate and colorectal cancer (CRC). MMP-2, by degrading basement membrane, facilitates
tumor cell invasion and metastasis formation. MMP-2 is also thought to promote tumor angiogenesis by
facilitating Endothelial Cell migration and VEGF release. The impact of minimally invasive colorectal
resection (MICR) for CRC on plasma MMP-2 levels is unknown. This studys aim was to measure plasma
MMP-2 levels during the first postoperative (postop) month.
Method: CRC patients undergoing MICR who were enrolled in an IRB approved data/plasma bank for
whom adequate plasma samples were available were eligible. Prospectively gathered clinical, operative and
pathological data were utilized. Blood samples were collected Preop and at varying postop time points and
were stored at -80C. Only patients for whom Preop, Postop day (POD) 1, 3 and at least 1 late postop plasma
sample (POD 741) were available were included in the study. The late samples were bundled into 7 day
time blocks and considered as single time points. MMP-2 levels were analyzed in duplicate via ELISA and
the results reported as mean and SD .The paired t-test was used for analysis. (Significance, p\0.008 after
Bonferronis correction).
Results: A total of 101 CRC (rectal, 27%; colon, 63%) patients that underwent MICR were studied (51 males /
49 female, mean age 66.5 12.8 years). The mean incision length was 8.2 4.2cm and mean LOS 6.8 4.1
days. The cancer stage breakdown was: Stage I, 34%; Stage II, 29%; stage III, 33%; and stage IV, 5%.The mean
PreOp MMP-2 level (ng/ml) was 176.840.6 (n=101). Significantly elevated mean plasma levels were noted
on POD1 (213.049.2, n=100,p=\ 0.0001), POD3 (256.365.9,n=90,p=\ 0.0001), POD713(227.560.2,
n=75,p=\0.0001), POD 1420 (236.045.9,n=29,p=0.003), POD 2127 (231.064.2,n= 21,p=0.0003 and on
POD 2841 time point (261.761.1,n=18,p=0.0005).
Conclusion: Plasma MMP-2 levels are significantly elevated from baseline for over 4 weeks after CRC
MICR. The etiology of these changes in unclear, however, surgical trauma-associated inflammation may
account for the early increase whereas tissue remodeling associated with wound healing likely accounts for
the mid and late postop elevations. Increased MMP-2 levels may promote tumor growth in residual tumor
deposits and formation of metastases. Further study is warranted.

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P048

P049

Usefulness of Needle-Guided Laparoscopic Abdominoperineal

Resection for Low Rectal Cancer

Laparoscopic Sigmoidectomy for Complicated Diverticular

Disease

Takehito Yamamoto, Akiyoshi Kanazawa, Ryo Ohno, Hiroyuki

Matsubara, Toru Goto, Takuya Okamoto, Yoichiro Uchida, Shugo
Ueda, Akira Mori, Hiroaki Terajima, Kitano Hospital,The Tazuke
Kofukai Medical Research Institute

Asem Ghasoup, MD, FACS1, Turki Al Qurashi, MD1, Mohammed

Widinly, MD1, Omar Sadieh, MD, FACS2, 1Security Forces Hospital
Makkah, 2Saad Specialty Hospital

Introduction: During laparoscopic abdominoperineal resection (APR) for low rectal cancer, prevention of
circumferential resection margin (CRM) involvement is important. Laparoscopic APR is superior to open
APR because it allows for direct and precise visualization of the deep intrapelvic space. However, the local
recurrence and survival rates after APR are reportedly not lower than those associated with anterior
resection. One reason for this is the difficulty in properly resecting the levator muscles to prevent CRM
involvement. We implemented a method that allows for resection of the levator muscles without closely
approaching the rectal wall and that creates a cylindrical specimen.
Methods and Procedures: The mesorectum is dissected caudally to the level of the levator muscle, and the
ureter and pelvic autonomic nerves are carefully protected during dissection. The surgeon inserts the needle
through the perineum from the dorsal side of the anus to the internal aspect of the tip of the sacrum. The
levator muscles and fat tissue are resected laparoscopically following the needle, which emerges from the
levator muscles. The specimen is resected from the perineum following the needle, and the intra-abdominal
space is easily reached.
Results: Laparoscopic needle-guided resection of the levator muscles is safe and superior to the conventional procedure because it avoids the surgical waist caused by conventional APR and easily prevents CRM
involvement.

Background: laparoscopic colo-rectal surgery has shown its advantages in terms of reduced post-operative
pain, earlier recovery of intestinal peristalsis and shorter hospital stay.

Few studies reported results of laparoscopic surgery in complicated diverticulitis. The aim
ofThis study to analyze the results of laparoscopic sigmoidectomy in patients with fistulized
sigmoiditis.
Methods: we reviewed 8 patients operated on for fistulized sigmoidectomy between January 2010 to
December 2014, in a series of 60 laparoscopic colectomies. five patients presented with colo-vesical fistula,
two with colo-cutaneous fistula and one with complicatged colo-cutaneous and coli-vesical fistula and all
were caused by sigmoiditis. The procedure always consisted in laparoscopic sigmoidectomy with stapled
transanal suture and eventually closure of the cystic orifice.
Results: Mean age was 54 years (range: 39 to 70 years). Mean number of diverticulitis crises before
operation was 3 (range: 1 to 5). Mean time between the last crisis and operation was 32 weeks (range: 2 to
120 weeks).The mean operating time was 120 min (range: 90 to 180 min). Mean hospitalization stay was 5.7
days (312 days). Mortality rate was 0%. Postoperative morbidity (0%). Long-term follow-up demonstrated
no diverticultis recurrence.
Conclusion: laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized diverticular
sigmoiditis if it is done by a trained surgeon.

Conclusion: Needle-guided laparoscopic APR can be easily and safely performed to reduce CRM
involvement. This technique contributes to the standardization of laparoscopic APR.

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P050

P052

Single Incision Plus One Port Laparoscopic Anterior Resection

for Rectal Cancer

Perioperative Outcomes in Laparoscopic Multivisceral Resection

of Primary Colorectal Cancer

Yasuhiro Ishiyama, Yasumitu Hirano, Kenji Douden, Masakazu

Hattori, Yasuo Hashidume, Fukui Prefectural Hospital

Kazuhiro Sakamoto, Shunsuke Motegi, Yurika Makino, Shingo

Kawano, Kazuhiro Takehara, Shinya Munakata, Koichiro Niwa, Shun
Ishiyama, Kiichi Sugimoto, Hirohiko Kamiyama, Makoto Takahashi,
Hiromitsu Komiyama, Yutaka Kojima, Michitoshi Goto, Atsushi
Okuzawa, Yuichi Tomiki, Department of Coloproctological Surgery,
Juntendo University, Tokyo, Japan

Background: We have developed single-incision plus one port laparoscopic anterior resection of the rectum
(SILS+1-AR) as a reduced port surgery in which we can utilize the incision for drainage as an additional
access route for laparoscopic procedures including the transection the lower rectum. In this retrospective
study, the perioperative and oncologic outcomes of SILS+1-AR were reported and showed surgical
procedure.
Methods: A Lap protector (LP) mini was inserted through a 2.5 cm transumbilical incision, and an EZaccess was mounted to LP and two 5-mm ports and one 12-mm port were placed in EZ-access. A 12 mm
port was inserted in right lower quadrant. Almost all the procedures were performed with usual laparoscopic
instruments, and the operative procedures were much the same as in usual laparoscopic low anterior
resection of the rectum using a flexible 5mm scope. The rectum was transected normally using only one
endoscopic linear stapler inserted from the right lower quadrant port.
Results: 124 consecutive patients underwent a single incision plus one port anterior resection for rectal
cancer between August 2010 and March 2015. Mean operating time was 180 (range, 81350) min, with an
estimated blood loss of 20 ml. No intraoperative complications or conversions to conventional laparoscopic
surgery. Four cases converted open surgery. Four patients required conversion due to the great size of the
tumor. 1 case necessitated additional ports. The median times to first postoperative liquid and solid intake
were 2 and 3 days, respectively. Most patients were discharged on postoperative day 10. Postoperative
complication occurred in the 124 of the 7 cases (5.9%) Complications included five anastomotic leakages
(4.0%), one intra-peritoneal abscess (0.8%), one small bowel obstruction (0.8%). The median follow up time
was 30 months. Six patients developed recurrence. One patient had died of local recurrence.
Conclusions: In our experience, a single incision plus one port laparoscopic anterior resection for rectal
cancer has been shown to be safe and feasible, with operative and oncological outcomes comparable to
conventional laparoscopic surgery.

Introductions: Laparoscopic surgery for colorectal cancer has been widely performed as a surgical treatment option. However, the use of laparoscopic surgery for locally advanced colorectal cancer invading or
adhering to adjacent organs or structures is controversial because of oncological and technical issues. The
aim of this study was to evaluate the feasibility of laparoscopic multivisceral resection of colorectal cancer.
Method: Between January 2010 and May 2015, 34 patients underwent multivisceral resection of primary
colorectal cancer invading or adhering to adjacent organs or structures. The tumors were located in the right
colon (n = 10), left colon (n = 18), and rectum (n = 6). Of the patients, 17 were male and 17 were female,
with a median age of 71 years (4586 years).
Results: The distribution of the resected adjacent organs or structures was as follows: abdominal or pelvic
lateral wall, n = 7; small bowel or colon and rectum, n = 7; vagina or uterus, n = 7; peritoneum, n = 5;
bladder, n = 4; vessels, n = 3; and seminal vesicles and levator ani muscle, n = 1. One patient had two
resected organs (the bladder and small bowel). Conversion to open surgery occurred in 6 patients (17.6%).
Although intraoperative complications were observed in 3 patients, these complications were managed
laparoscopically. Postoperative complications occurred in 4 patients (11.8%), which were classified as grade
2 according to the Clavien-Dindo classification system. Reoperation was not required. The mean operation
time was 306 min (range, 252556 min), and blood loss was 47 mL (10450 ml). Pathological invasion to
other organs (pT4b) was confirmed in 17 patients (50%). Four patients had residual pathological tumors,
corresponding to an R0 resection rate of 88.2%. The pathological TNM classification was stage 2 in 14
patients, stage 3 in 11 patients, and stage 4 in 9 patients. The mean postoperative hospital stay was 11 days
(range, 822 days).
Conclusions: For primary colorectal cancers, the use of laparoscopic multivisceral resection is feasible for
carefully selecting patients and diagnosing the involvement of adjacent organs. Conversion to open surgery
before multivisceral resection is an important procedure to avoid dissemination of cancer cells and local
recurrence, if the tumor margin is unclear, or if massive adherence to adjacent organs or structures is
observed laparoscopically.

P051

P053

Evaluation of the Lymphatic Flow at the Splenic Flexure

in the Laparoscopic Colon Cancer Surgery

Laparoscopic Colectomy with Intracorporeal Anastomosis

for Early-Staged Colon Cancer

Jun Watanabe1, Mitsuyoshi Ota2, Yusuke Suwa1, Hirokazu Suwa2,

Masashi Momiyama3, Atsushi Ishibe3, Kazuteru Watanabe4,
HIdenobu Masui1, Kaoru Nagahori1, 1Department of Surgery,
Yokosuka Kyosai Hospital, 2Department of Surgery,
Gastroenterological Center, Yokohama City University, 3Department
of Gastroenterological Surgery, Yokohama City University Graduate
School of Medicine, 4Department of Surgery, NTT Medical Center
Background: Complete mesocolic excision (CME) and central vascular ligation (CVL) are nowadays state
of the art in the treatment of colon cancer that provides improved oncologic outcomes. However, the
treatment of colon cancer located in splenic flexure is not standardized because the lymphatic drainage at
this site is variable. It is considered that carcinoma at this site has dual lymphatic drainage of the Middle
colic artery (MCA) and left colic artery (LCA) areas and in addition, if it exists, accessory left colic artery
(aLCA) area. There is no systematic data in the literature on the frequency of lymphatic drainage root.
Purpose: The aim of this study is to evaluate the lymphatic flow at the splenic flexure.
Methods: From July 2013 to June 2015, we enrolled consecutive patients of colon cancer located in splenic
flexure with preoperative diagnosis of clinical N0. Primary outcome is frequency of the direction of lymphatic flow from splenic flexure. At first, we injected indocyanine green (2.5mg) to submucosal layer near
the tumor and observed lymphatic flow using the laparoscopic near-infrared camera system in 30 minutes
after injection.
Results: A total of 26 consecutive patients were enrolled in this study. These patients included 7 females,
and had a mean age of 66.8 years, a mean body mass index of 23.3 kg/m2. A mean duration of operation was
220 minutes and a mean blood loss was 62 ml. The presence of aLCA rate was 38% (10 cases). The
prevalence of direction of lymph flow type was 7 cases (26.9%) for LCA area, 5 cases (19.2%) for LCA and
aLCA areas, 5 cases (19.2%) for MCA area, 3 cases (11.5%) for aLCA area, 2 case (7.7%) for MAC and
aMCA areas. Lymph flow not accompanying artery directed to the root of IMV was 4 cases (15.4%). 0 case
(0.0%) for LCA and MCA areas. There are 14 cases (53.8%) with lymph flow directed to the area of root of
IMV if aLCA exist or not. a number of retrieved lymph nodes (LNs) was 17.6 and fluorescence LNs was
10.7. LN metastases were 6 cases, but were all lymph flow areas domain by the fluorescence lymphatic flow
evaluation.
Conclusion: In CME and CVL for colon cancer located in splenic flexure, we should perform LN dissection
of the root of IMV area plus LCA area or MCA area by the fluorescence lymphatic flow evaluation, and LN
dissection of 3 areas is not necessary.

123

Fumihiko Fujita, MD, Yusuke Inoue, MD, Masahiko Nakayama, MD,

Hiroko Kinoe, MD, Yuka Mine, MD, Shinichiro Kobayashi, MD,
Kengo Kanetaka, MD, Kosho Yamanouchi, MD, Kazuma Kobayashi,
MD, Tamotsu Kuroki, MD, Susumu Eguchi, MD, Nagasaki
University Graduate School of Biomedical Sciences
Introduction: Conventional laparoscopic assisted surgery for colon cancer requires small skin incision for
the extraction of the specimen and the ensuing anastomosis. For selected cases, we performed laparoscopic
colon resection with an intracorporeal anastomosis in order to reduce incision. We presented our surgical
technique and preliminary outcomes at SAGES meeting in 2012. At this time, we show our consecutive
surgical outcomes until now.
Methods and Procedures: We retrospectively collected the data, and analyzed the patients who underwent
laparoscopic colectomy from February 2011 to July 2015. The intracorporeal anastomotic method was
selectively performed only for early-stage colon cancer. The surgical technique was as follows. Four or five
trocars were used, and the surgeon uses a 3 or 5 mm in diameter grasper with the left hand. First, the lesion
lymph nodes are dissected. The lesion of the colon is transected using a linear stapler with adequate margins
on both the oral and anal cut ends. Both ends of the intestines were over lapped for 6cm in the opposite
direction. A laparoscopic linear cutting stapler is deployed through the bowel opening, to form a side-to-side
isoperistaltic anastomosis. The enterotomy is closed with full thickness 30 vicryl continuous suture, and a
seromuscular continuous suture is added. The resected specimen enclosed in a bag can be extracted through
one of the trocar sites without laparotomy. We compared the results of the intracorporeal anastomosis with
extracorporeal anastomosis, and analyzed the data for statistical significance.
Results: Laparoscopic intracorporeal anastomosis was successfully performed for 20 consecutive patients
(10 male and 10 female). The average age was 66.3 years, and the locations of the tumors were 8 in the
sigmoid colon, 4 in the descending colon, 3 in the ascending colon, 3 in the cecum and 2 in the transverse
colon. The average length of the operation was 223.6 minutes, and the estimated blood loss was 19.2 ml.
There was no case that was converted to open surgery. Although one case was complicated by a wound
infection, there were no major complications, such as anastomotic leakage or stricture. Intracorporeal
anastomosis method was superior in estimated blood loss during the surgery to extracorporeal anastomosis
method, and there was no statistical difference in the operation time between two groups.
Conclusions: The laparoscopic intracorporeal anastomotic method can be performed safely, and has the
benefit of inducing minimal abdominal wounding and less blood loss in comparison to extracorporeal
anastomosis.

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S331

P054

P056

Alvimopan in the Setting of Colorectal Resection with an Ostomy:

To Use or Not to Use?

Comparison Between Younger, Middle and Elderly Patients

in Laparoscopic Surgery for Colon Cancer

Yuxiang Wen, BM, Murad A Jabir, MD, Michael Keating, BA,

Alison R Althans, BA, Justin T Brady, MD, Bradley J Champagne,
MD, Conor P Delaney, MD, MCh, PhD, Scott R Steele, MD,
University Hospitals Case Medical Center/Case Western Reserve
University

Emiko Takeshita, MD, Yoshihisa Saida, MD, Toshiyuki Enomoto,

Kazuhiro Takabayashi, Sayaka Nagao, Yoichi Nakamura, MD,
Ryohei Watanabe, MD, Yasushi Nagaoka, MD, Natsuya Katada, MD,
Manabu Watanabe, MD, Koji Asai, MD, Shinya Kusachi, MD,
Department of Surgery, Toho University Ohashi Medical Center

Introduction: Postoperative ileus (POI) is a major cause of morbidity, increasing length of

stay (LOS) and hospital costs after colorectal surgery. Many efforts have been made to
decrease the rate of POI. Alvimopan is a mu opioid antagonist approved to accelerate upper
and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan
would reduce LOS in patients undergoing colorectal resection with stoma.
Methods and Procedures: Over an 8 year period (20062014), 725 patients underwent
colorectal resection for both benign and malignant disease with stoma creation at a single
academic medical center. The 58 patients who received alvimopan were matched to 116
non-alvimopan patients based on age, diagnosis and procedure performed. We compared
overall LOS, incidence of POI, and other postoperative complications.
Results: There were 18 laparoscopic and 40 open resections in the alvimopan group and 23
laparoscopic and 93 open resections in non-alvimopan group. 39 patients underwent
resection for malignant disease and 19 patients underwent resection for benign disease in
the alvimopan group. Of the patients who did not receive alvimopan, 87 patients underwent
resection for malignant disease and 29 patients underwent resection for benign disease.
Mortality was similar at 0 vs. 1.7%. There was no significant difference in median LOS
(alvimopan 5.89 vs. control 6.69 days, P=0.15). Reoperation rates (5.2% vs. 5.2%, p[0.05)
and complication rates (43.1% vs. 52.6%, p=0.238) were comparable. Readmission rate
within 30 days was similar between groups (alvimopan 22.4% vs. control 20.7%, P=0.793).
Conclusions: The use of alvimopan in patients undergoing colorectal resection with stoma
is not associated with a shorter LOS, or decreased readmission or complication rates.
Pending further larger clinical trials, alvimopan should be reserved for patients undergoing
primary anastomosis without diversion.

Purpose: The aim of the present study was to assess the validity of laparoscopic surgery for
colon cancer in younger, middle and elderly patients.
Patients and Methods: The subjects selected for this study were a total of 273 consecutive
patients who were diagnosed with primary colon cancer and those who underwent
laparoscopic surgery between January 2000 and December 2010 at our hospital. We retrospectively analyzed and compared the preoperative clinicopathological features of the
three different age groups: group A (32- 69years); group B (70- 79years)and group C (8090years).
Results: Therewere134 patients in group A, 98 patients in group B and 41 patients in group
C. The comorbidity of group A was 38%, group B was 53% and group C was 63%
(P\0.01).
The operation time of group A was 197.66.4 minutes, group B; 202.56.99 minutes and
group C; 182.710.8 minutes (N.S.). The average blood loss of group A was 66.2ml, group
B; 53.5 ml and group C; 55.1 ml (N.S.). The average postoperative days for oral intake in
group A was 3.2 days, group B; 3.1days and group C; 3.0 days. The rate of overall
incidence of postoperative complication after laparoscopic surgery in group A was 17%,
group B; 14% and group C; 17% (N.S.). The average hospital stay of group A was 11.6
days, group B; 10.3 days and group C; 11.1 days (N.S.). Early postoperative mortality was
null. Among the three age groups, there were no statistically significant findings in gender,
Dukes stage and the grade lymph node dissection.
Conclusions: These results suggest the efficacy of laparoscopic surgery for colon cancer in
elderly patients in their 70s and 80s as well as in middle and younger patients.

P055

P057

Selective Lateral Pelvic Lymph Node Dissection: Comparative

Study of Robot Versus Laparoscopic Approach

When You Gotta Go: A High Resolution Anal Manometry Study

Evaluating the Urge to Defecate in Patients with Mixed Fecal
Incontinence and Obstructed Defecation

Hye Jin Kim, Gyu-Seog Choi, Jun Seok Park, Soo Yeun Park, Hee Jae
Lee, Kyungpook National University Medical Center, School
of Medicine, Kyungpook National University, Daegu, Korea
Background: Lateral pelvic lymph node dissection (LPND) is a challenging procedure due
to its technical difficulty and higher incidence of surgical morbidity. The present study
compared the short-term outcomes for laparoscopic versus robotic LPND in rectal cancer
patients.
Methods: Between May 2006 and December 2014, prospectively collected data from
consecutive patients who underwent robotic or laparoscopic total mesorectal excision
(TME) with LPND were retrospectively compared. Data regarding patient demographics,
perioperative outcomes, functional results, and initial oncologic outcomes were analyzed.
Results: Fifty and 35 patients underwent robotic or laparoscopic TME with LPND,
respectively. Bilateral LPND was performed in 10 patients (20%) in the robotic group and 6
patients (17.1%) in the laparoscopic group. For unilateral pelvic dissection, the mean
operative time did not show significant difference between groups (robot vs. laparoscopic
group, 41.0 15.8 vs. 35.3 13.4 min; P = 0.146), but the estimated blood loss was
significantly lower in the robotic group (34.6 21.9 vs. 50.6 23.8 mL; P = 0.002). Two
patients (4.0%) in the robotic group and 7 patients (30.4%) in the laparoscopic group
experienced Foley catheter reinsertion for their urinary retention, postoperatively (P =
0.029). The impairment of urinary function, analyzed by total IPSS after surgery, was lower
in the robotic group. The mean number of harvested lateral pelvic lymph nodes was 6.6
(range, 025) in the robotic group and 6.4 (range, 114) in the laparoscopic group. During
median follow-up of 26.3 months, 2 patient in the robotic group and 4 patients in the
laparoscopic group experienced local recurrences.
Conclusions: Robotic TME with LPND was safe and feasible with favorable short-term
surgical outcomes. Further large cohort studies and long-term follow-up are warranted.

Elyse LeeVan, MD1, Aaron Lewis, MD2, Alex Huang1, Gabriel

Akopian, MD1, Howard Kaufman, MD1, 1Huntington Hospital, 2City
of Hope
Objectives: In the past 5 years, three-dimensional high resolution anorectal manometry (3D
HRAM) has replaced traditional perfusion catheters in the evaluation of defecatory disorders. Our objectives were to utilize 3D HRAM to identify physiologic differences between
groups of female patients with fecal incontinence (FI), obstructed defecation, and mixed
disorders (both obstructive and incontinent symptoms), to evaluate these relationships in
male patients, and to determine the relationship between the rectal sensory threshold urge to
defecate and sphincter function, specifically, mean resting sphincter tone, residual anal
pressure, and percent anal relaxation.
Methods: A retrospective chart review of of 77 females and 27 males was performed using
anorectal physiology reports for patients undergoing 3D HRAM for evaluation of defecatory disorders between January 1, 2013 and April 1, 2015 at a single institution. Exclusion
criteria included patients with rectal cancer and ileal j-pouches. Remaining patients were
categorized into three groups: incontinent, obstructed, and mixed based on presenting
symptoms. Physiologic values including mean resting sphincter pressure, maximal squeeze
pressure, residual anal sphincter pressure, percent anal relaxation, and sensory threshold of
urge to defecate were recorded. Kruskal-Wallis tests were performed to assess differences
with regards to physiologic variables between groups. Bivariate correlation tests were
performed to assess the relationship between these variables within groups. SPSS was
utilized for statistical analysis.
Results: Women with mixed defecatory disorders had mean resting pressures and maximum squeeze pressures that were significantly different from patients with pure FI or
obstruction. Men with mixed defecatory disorders had only mean resting pressures that
were significantly different from patients with pure FI or obstruction. In females with mixed
defecatory disorders there was a positive correlation between the rectal sensory threshold
urge to defecate and the resting mean sphincter pressure, residual anal bear down pressure,
and percent anal relaxation (p values 0.021, 0.036, 0.006 respectively). These relationships
were not demonstrated in the incontinent or obstructed defecation groups.
Conclusion: Females and males with mixed defecatory disorders demonstrate unique, but
distinct physiologic profiles that can be characterized using 3D HRAM. The female mixed
defecatory group demonstrates relationships between physiologic parameters that are not
seen in the incontinent or obstructed groups. These relationships provide further insight into
the etiology of this poorly described disease process and may aid in developing treatment
regimens.

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P058

P060

Extralevator Versus Standard Abdominoperineal Excision: Does

Radiotherapy Play A Part in Wound Breakdown?

Short & Middle Term Results of Lower Rectal Cancer According

to Procedure

A Musbahi, D Kamali, A Sharpe, Y Viswanath, A Reddy, James

Cook University Hospital, Middlesbrough UK

Toshimasa Ishii, PhD, Shigeki Yamaguchi, Prof, Saitama medical

university international medical center

Introduction: Little data are available on post-operative outcomes of extralevator abdominoperineal

excision (ELAPE) such as wound complications, herniation and infections compared to standard
abdominoperineal excision (SAPE). ELAPE is purported to have a better oncological outcome than SAPE.
However, due to the larger perineal defect, it is postulated that there is a greater perineal wound breakdown
and herniation after ELAPE than SAPE. This study evaluated the association between wound breakdown
and the use of pre-op radiotherapy in either of ELAPE and SAPE.
Methods: Data were collected on all ELAPE and SAPE resections at a single major surgical unit for patients
with rectal cancer between January 2009 and December 2014. Information was collected on length of stay,
pre-op staging, histological grading, pre-op CEA measurement, pre-op CT and MRI results as well as postop complications including perineal wound breakdown, diabetes and immunosuppression status. Patient
notes and computer records were reviewed to obtain data on perineal wound complications, specifically
wound breakdown and symptomatic perineal herniation. Categorical data was analysed using Fisher exact
test where appropriate. A P value of \0.05 was considered as significant,
Results: Data on 45 patients (35 male; mean age 67.4 years; 24 ELAPE and 21 SAPE) were recorded. 39/45
(87%) patients had radiotherapy prior to surgery [20/24 ELAPE and 19/21 SAPE]. 10/24 ELAPE and 5/21
SAPE developed wound breakdown. 3/4 of patients with diabetes developed wound breakdown. Of the
ELAPE patients who had undergone prior radiotherapy, 7/20 had wound breakdown, one of whom was
diabetic. There was no significant difference in the number of patients with wound breakdown in the ELAPE
group with and without pre-op radiotherapy. 5/19 SAPE patients who had pre-op radiotherapy developed
wound breakdown. 2/5 were diabetics. The two remaining patients without adjuvant radiotherapy in the
SAPE group did not develop wound breakdown. Radiotherapy was not a significant factor in wound
breakdown in patients undergoing SAPE. There was no significant difference in wound breakdown in the
SAPE group between radiotherapy and wound healing. There was no perineal herniation in either group of
patients.
Conclusion: Radiotherapy is common in patients undergoing abdominoperineal resection of either type.
Wound breakdown rates were high in both surgical group of patients, in particular those who underwent
ELAPE. However, radiotherapy was not a significant factor in wound breakdown between either group.
Furthermore, there was no significant difference in wound breakdown in diabetic patients in either group.

Purpose: Since April 2007 of hospital opening, we tried to perform intersphincteric resection (ISR) and
laparoscopic resection (Lap) for lower rectal cancer. This study was assessed short term results for recent 7
years.
Patients: One hundred fifty-four patients of curative advanced lower rectal cancer laparoscopic resection
(Stage II, III) were included in this study. There are 107 males and 48 females. Each number of procedure
was; low anterior resection (LAR) 87, ISR 46, Abdomino-perineal resection (APR) 22. Thirty patients
received lateral lymphadenectomy. All cases of LAR and ISR had diverting stoma. The mean follow-up
length were 934.3 days.
Method: We analyzed retrospectively. Statistical analysis of short term results was performed using Students t-test and chisquare test method. 3-years disease free survival rate (middle term result) was calculated
using Logrank method.
Results: There in no motality and all patients returned to normal daily life after surgery. Mean operating
time, mean blood loss count, and mean postoperative hospital stay (median) were LAR 259 min., 22 g, 10
days, ISR 332 min., 76 g, 9 days, APR 283 min., 94 g, 11 days, respectively. Regarding postoperative
complication rates, anastomotic leakage, intestinal obstruction, and wound infection were LAR 11.5 %, 13.8
%, 1.1 %, ISR 4.3 %, 8.7 %, 0%, APR -%, 0 %, 22.7 %. There were no difference of postoperative
complications between LAR and ISR and APR. But APR were difference of wound infection. There were no
difference of 3-years disease free survival rate (LAR 76.2 %, ISR 69.7 %, APR 81.9 %).
Conclusion: Short & middle term results of laparoscopic resection for lower rectal cancer in a single center
were similar to that each procedure. Laparoscopic resection for lower rectal cancer was usually already
operations.

P059

P061

A New Composite Program to Eliminate Anastomotic Leakage

in Laparoscopic Colorectal Surgery

Single Incision Laparoscopy as a Standard for Colorectal

Resections for Cancer

Hitoshi Idani, MD, FACS, Hiroyuki Araki, MD, Soichiro Miyake,

MD, Hisanobu Miyoshi, MD, Kazutaka Takahashi, MD, Toshihiko
Fujita, MD, Naoki Mimura, MD, Toshihiro Ogawa, MD, Yasuhiro
Komatsu, MD, Hiroaki Inoue, MD, Kenji Yamaguchi, MD, Hijiri
Matsumoto, MD, Yasuo Nagai, MD, Masao Harano, MD, Yasutomo
Ojima, MD, Noriaki Tokumoto, MD, Hiroyoshi Matsukawa, MD,
Takashi Kanazawa, MD, Yasuhiro Choda, MD, Daisuke Sato, MD,
Michihiro Ishida, MD, Shigehiro Shiozaki, MD, Masazumi Okajima,
MD, FACS, Motoki Ninomiya, MD, Department of Surgery
Hiroshima City Hospital

Elie K Chouillard, PARIS POISSY MEDICAL CENTER

Background: Anastomotic leakage (AL) is still a crucial matter in colorectal surgery. We have introduced a
new program to eliminate AL in laparoscopic colorectal surgery and evaluated the outcome.
Methods: Our program consisted of basic care and surgical protocol. The former included smoking cessation, control of blood sugar and nutrition, lactobacillus preparation, disuse of NSAIDS and continuous use
of aspirin. The latter included surgery with meticulous hemostasis, anastomosis by linear stapler in
colectomy and double stapling technique in anterior resection (AR) with reinforcement sutures at all staple
on staple site. Especially in AR, the left colic artery was reserved as long as possible, the rectum was
resected with one stapler or two (planned) in which staple on staple site was resected by circular stapler and
anastomosis was confirmed by intraoperative colonoscopy. Pelvic drain was used and trans-rectal decompression tube was used if needed. From January 2014 to August 2015, 91 out of 226 patients who underwent
laparoscopic colorectal surgery were enrolled in this program. The occurrence of AL in every grade of
Clavien Dindo classification (CDC) was evaluated separately in colon surgery and in AR.
Results: There was no leakage in every grade of CDC in 61 colon surgery. Patients underwent AR consisted
of 21 men and 10 women with a mean age of 64.3 years. Body mass index was 23.3. Location of the tumor
was Rs: 5/Ra: 14/Rb: 12. Comorbidities were as follows; diabetes mellitus: 4, aspirin use for coronary stent:
4, warfarin use: 2, chronic renal failure with hemodialysis: 1. High AR, low AR and super low AR were
performed on 5, 24 and 2 patients, respectively. Operation time and blood loss were 223 min and 32.8g,
respectively. The number of stapler used for rectal resection was one: 24, two: 6, three: 1. Bilateral
reinforcement sutures were achieved laparoscopically in 28 (90.3%) patients. Diverting ileostomy was
added on 4 patients. Pelvic drain was used in all patients, however, trans-anal tube was never used. The
distance from anal verge to the anastomosis was 5.91.8 cm. Mean postoperative stay was 10.4 days and
there was no leakage in every grade of CDC, whereas there were 6 leakages (grade 2/3: 4/2) in patients who
have not enrolled in this program.
Conclusion: Our new composite program can minimize the risk of anastomotic leakage in laparoscopic
colorectal surgery. Reinforcement sutures may play an important role to improve resistant pressure at the
anastomosis.

123

Introduction: The concept of Natural Orifice Translumenal Endoscopic Surgery (NOTES) contributed to
the evolvement of single port laparoscopy. Accessing the abdominal cavity solely through the umbilicus
shifted laparoscopy from a multiport to a single port procedure. Proponents of this approach to further
reduce the invasiveness of laparoscopic surgery with fewer abdominal wall complications, less postoperative
pain, faster return to activity, and better cosmesis. This study reports the mid-term results of single port
colorectal resections for cancer (sCR) in our institution.
Methods and Procedures: All patients who had single port laparoscopic procedures were prospectively
included in a database created in 2009. A single 25 to 35-mm diameter, umbilical (or right or left lower
quadrant) incision was used. Three 5-mm ports (or two 5-mm and one 12-mm) were inserted through a
special platform device. Exclusion criteria comprised total mesorectal excision, ASA III status, organ
insufficiency, and hemostasis disorders.
Results: From January 2009 to December 2014, sCR was attempted in 278 patients (right, left, transverse,
total). During the same study period 111 patients were operated either openly or using standard multiport
laparoscopy. An analysis of the distribution of the procedures per year is performed.
Regarding patients who had sCR, the success rate without conversion to laparotomy was 89.7 %. Additional
procedures included cholecystectomy (24), oophorectomy (10), intraperitoneal chemohyperthermia (8),
duodenal resection (2), hysterectomy (7), and atypical liver resection (6). Mortality rate was nil. The overall
morbidity rate (mainly minor complications) was 12.8 %. Eleven patients had leaks (3.9 %).
Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with colorectal disease,
either benign or malignant. Advantages regarding postoperative pain and length of hospital stay could be
demonstrated. However, larger scale, studies are needed for further evidence-based analysis, especially
regarding oncological outcome.

Surg Endosc (2016) 30:S325S500

S333

P062

P064

Outcomes of Surgery with Colonic Stents for Obstructive Colon

Cancer

Surgical Outcomes of Laparoscopic Right Colectomy

in Octogenarians

Yu Sato, MD, PhD, Yoshimasa Gohda, MD, Tomoko Horie, MD,

Tsuyoshi Takaya, MD, Ryuichiro Suda, MD, Yasutaka Syuno, MD,
PhD, Hideaki Yano, MD, PhD, Department of Colorectal Surgery,
National Center for Global Health and Medicine

Ron Shapiro, MD1, Uri Keler, MD1, Hatib Kamal, MD2, Guy Pascal,
MD2, Aviram Nissan, MD1, David Hazzan, MD2, 1Chaim Sheba
Medical Center, 2Carmel Medical Center

Objective: This study is aimed at evaluating the outcomes of colonic stents used as a bridge to surgery in the
management of obstructive colorectal cancer.

Methods: We retrospectively identified nine consecutive patients who underwent colonic

self-expanding metallic stents (SEMSs) as a bridge to surgery in the management of
malignant colonic obstruction in our institution from July 2012 to December 2013. The
main outcome measures were the technical success rate, short-term results of surgery,
recurrence and overall survival.
Results: All patients had obstructive tumor in the left colon. Of these patients, 55.6% had localized colon
cancer without metastasis. Procedural success was 77.8% (7/9). Clinical success was 66.7% (6/9). Elective
surgery was performed in 8 patients (7 laparoscopic, 1 open, 1 converted) and 1 emergency surgery in 1
patients for treatment of stent occlusion due to growth of tumor (1 stoma). Median time between stent
placement and surgery was 9 days (range 615). The postoperative complication rate was 22.2% (2/9). The
median postoperative hospital stay was 11 days (range 749). The recurrence rate was 50% and mean time
to recurrence was 13 months. Median survival was 27 months (range 1337).
Conclusions: SEMSs provide an effective bridge to surgery treatment in patients with malignant colonic
obstruction, allowing elective surgery with an acceptable complication rate. However, our results suggest
long-term outcomes of patients with a bridge to surgery might be worse.

P063
Propensity Score Analysis in Comparisons of Long-Term
Outcomes for Locally Advanced Colon Cancer Between
Laparoscopic Colectomy and Open Colectomy
Kiichi Sugimoto, Kazuhiro Sakamoto, Yuichi Tomiki, Michitoshi
Goto, Yutaka Kojima, Hiromitsu Komiyama, Makoto Takahashi,
Hirohiko Kamiyama, Shun Ishiyama, Koichiro Niwa, Shingo Ito,
Masaya Kawai, Shingo Kawano, Kazuhiro Takehara, Shinya
Munakata, Jun Aoki, Yu Okazawa, Rina Takahashi, Kousuke
Mizukoshi, Hisashi Ro, Ryosuke Ichikawa, Kazumasa Kure, Kumpei
Honjo, Ryoichi Tsukamoto, Department of Coloproctological
Surgery, Juntendo University Faculty of Medicine
Introduction: Laparoscopic colectomy (LAC) for colon cancer has been applied to locally advanced colon
cancer. However, because there have been some biases in the indications between LAC and Open colectomy
(OC) for locally advanced colon cancer, we cant simply compare the long-term outcomes between the two
procedure on non-randomized conditions. Here, we retrospectively compared the long-term outcomes
between LAC and OC using propensity score adjustment.
Methods: 226 patients who underwent colectomy (LAC: 98 patients, OC: 128 patients) for curative intent at
our department between 2004 and 2010 were enrolled in the present study. Propensity score analysis was
used to adjust for differences in severity of clinicopathological factors between the patients who underwent
LAC and OC. The estimated probability that a patient underwent LAC was modeled for potential confounders: year of surgery (-2006 / 2007-), age, location (C, A / S, RS), invasion depth (T13 / T4), American
Society of Anesthesiologists (ASA) score (1, 2 / C 3) and the diameter of primary tumor (\ 50 / C 50mm).
The discrimination of the propensity model was assessed with calculation of the c-statistic. The propensity
score was subsequently incorporated into a proportional hazards model as a covariate. The Cox proportional-hazard model was used to determine Hazard ratios and 95% confidence intervals.
Results: There was a significant difference between the LAC group and the OC group in recurrence-free
survivals (LAC; Hazard ratio= 0.59, 95% CI 0.350.98, P=0.04). On the other hand, there was no significant
difference in cancer-specific survivals between the two group (LAC; Hazard ratio= 0.63, 95% CI 0.271.37,
P=0.25). The median propensity score was 0.31 (0.090.93) in the LAC group, and 0.82 (0.080.99) in the
OC group (P\0.0001). The c-statistic was 0.85, indicating satisfactory discrimination. After propensity
score matching analysis, there were no significant differences between the LAC group and the OC group in
recurrence-free survivals (LAC; Hazard ratio= 0.91, 95% CI 0.412.01, P=0.82) and in cancer-specific
survivals (LAC; Hazard ratio= 1.38, 95% CI 0.414.82, P=0.59). Similarly, the analysis using the propensity
score inverse probability weighting (IPW) estimator showed that there were no significant differences in
both RFS and CSS.
Discussion: Propensity score analysis revealed that there was no difference in both recurrence-free survivals
and cancer-specific survivals between the LAC group and the OC group. Therefore, this results suggested
that LAC for locally advanced colon cancer would be equivalent to OC in long-term outcomes.

Introduction: Surgical morbidity rates are higher in the elderly when compared to younger age groups. The
aim of this study was to evaluate the impact of age on operative results of laparoscopic right hemicolectomy.
Methods: This is a comparative study, according to age groups, of patients who underwent laparoscopic
right hemicolectomy for neoplasm of the right colon. Patients were divided into three groups: age\65 years
(GroupA) age 6579 (GroupB) and age[80 years (GroupC). Short and long-term outcomes were compared.
T-Test was used for continuous variables and Chi Square was used for analysis of categorical variables.
Results: 207 consecutive patients were included in the study, 48 in group A, 105 in group B and 54 in group
C. There was no statistically significant difference in the groups in terms of BMI and gender. Octogenarians
(GroupC) included a higher proportion of patients with existing comorbidities (GroupC- 70.4%, GroupB54.3%, GroupA- 35.4%, p=0.002), higher proportion of patients with ASA 3 and above (GroupC- 70.4%,
GroupB- 52.4%, GroupA- 33.3%, p=0.001), and a higher proportion of patients operated on for colon cancer
as well as patients with existence of other active malignancy. There was no difference between the groups in
the extent of the operation performed (Right colectomy vs. extended right colectomy) and anastomosis
technique (intracorporeal vs. extracorporeal). The operative time was shorter in the Octogenarians group
(GroupC- 139 minutes, GroupB- 147 minutes, GroupA- 159 minutes, p=0.036). Octogenarians (GroupC)
needed more blood transfusions (GroupC- 9.3%, GroupB- 0%, GroupA- 2.1%, p=0.005). There was no
statistically significant difference between the groups in overall rate of postoperative morbidity and mortality. Intra-abdominal infection (leak+abscess) rate was higher in the youngest age group (GroupA)
(GroupA- 8.3%, GroupB- 1%, GroupC- 1.9%, p=0.035). However, this did not result in differences between
the groups in terms of need for re-intervention and the Clavien-Dindo score. Length of stay was longer in
octogenarians (GroupC- 7 days, GroupB- 6.1 days, GroupA- 6 days, p=0.002). There was no statistically
significant difference in the occurrence of long-term complications, namely small bowel obstruction and
incisional hernia. Nevertheless, there was a trend towards a higher incisional hernia rate in octogenarian
(GroupC- 18.5%, GroupB- 7.6%, GroupA- 6.3%, p=0.061).
Conclusions: Laparoscopic right hemicolectomy does not result in increased morbidity and mortality in
octogenarians. Nevertheless, a longer recovery time should be expected when compared to younger age
groups.

P065
Safety & Efficacy of Synchronous Robotic Surgery for Colorectal
Cancer with Liver Metastases
Steven S Tsoraides, MD, Rozana H Asfour, MD, Matthew J Scheidt,
MD, J Stephen Marshall, MD, University of Illinois at Peoria
Introduction: Timing of resection & treatment of colorectal cancer (CRC) with liver metastases varies
based on patient characteristics & center protocols. Concerns of increased morbidity & mortality (M&M)
related to anesthetic time & blood loss have limited widespread adaptation of synchronous colorectal & liver
resections. Furthermore, technical challenges have made minimally invasive synchronous resections less
common. We present the first reported series of synchronous robotic surgery for CRC with liver metastases.
Methods & Procedures: Retrospective review of prospectively collected data of patients with stage IV
CRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who
underwent synchronous robotic surgery for CRC with liver metastasis(es) were included & selected by a
multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, &
complications. All resections were performed robotically by the same well-experienced surgeons. A radiologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of
intraoperative bleeding risk.
Results: Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Six
patients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years & mean BMI was 23.46. Mean
of 2 liver segments were involved. Four patients underwent metastatectomy; three with concurrent
microwave ablation. One patient had ablation without resection & another had no identifiable lesion on
ultrasound. The colonic resections included 3 low anterior resection, 2 abdominal perineal resections (APR),
& 1 right hemicolectomy. Mean operative time was 401 mins (349506 mins) with mean EBL of 316 mL
(1501000 mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days
(310 days). Complications included delayed wound healing after an APR & a rectal anastomotic failure
after ileostomy reversal. There was no 30-day mortality. At a mean follow up of 19 months, one death
occurred at 26 months & the remaining patients had documented metastatic disease.
Conclusions: Synchronous resection for metastatic CRC carries risks. We report the first series of synchronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss,
appropriate LOS, & no 30-day mortality. Morbidity experienced was consistent with the procedures & not
related to the robotic technique. This series supports the potential benefits of synchronous resection from a
technical standpoint. Further data is required to determine treatment & survival benefits. Limitations include
small number & retrospective review of data.

123

S334

Surg Endosc (2016) 30:S325S500

P066

P068

The Methodology to Stylize the Laparoscopic Surgery for Colon

Cancer for Education and Tradition

Reoperation Following Colorectal Surgery: Indications

and Operations

Hidekazu Takahashi, MD, Ichiro Takemasa, MD, Naotsugu

Haraguchi, MD, Junichi Nishimura, MD, Yasushi Hata, MD,
Hirofumi Yamamoto, MD, Tsunekazu Mizushima, MD, Yuichiro
Doki, MD, Masaki Mori, MD, Osaka University Graduate School
of Medicine, Gastroenterological Surgery

Alex D Michaels, Matthew G Mullen, Traci L Hedrick, Christopher

A Guidry, Florence E Turrentine, Charles M Friel, University
of Virginia Health System

Recent laparoscopic surgery benefit surgeons due to the microscopic effect of the targets
and knowledge of micro-anatomy obtained through high quality visualizations under HD
image. Thus, by performing laparoscopic surgery with fine and accurate manipulation,
surgeons could pursuit high quality and convincing procedures yield to the procedures
conducted by conventional operation through major laparotomy. However, acquisition of
appropriate technique for laparoscopic surgery is challenging and surgeons should at least
aware of laparoscopic-surgery specific weak point such as difficulty of acquisition of wide
and bird visualizations to accomplish safe and adequate procedure. In this line, for education and tradition of laparoscopic surgery, adequate training and standardized technique
thought to be critical.
Here, we present our original efforts to overcome these difficulties in laparoscopic surgery
for colon caner. First, 3-dimentional (3D)-triple fusion virtual images, which were constructed from multi-directional computed tomography (MDCT)/positron emission
tomography (PET) and air-colonography, were routinely obtained for decision of operative
strategy; e. g., dimension of lymph node dissection and location of ligation of the vessels,
shared by all operative team members preoperatively. Second, perioperatively, surgeons
refer obtained 3D-triple fusion virtual images for the navigation surgery on demand. By
doing these, surgeons could perform dissection by carefully tracing the embryologic tissue
plane to accomplish complete mesocolic excision (CME) and central vascular ligation
(CVL) which thought to be indispensable for curative resection for colon cancer.
From 2004 to 2011, 511 laparoscopic surgery for advanced colon cancer were performed in
line with our original efforts described above. The mean operative time was 175mins and
the mean blood loss was 30g. Five-year disease free survival rate was 86.7% at stageII and
76.1% at stageIII, respectively. Since 2009, we have been applied our method for single
incision laparoscopic surgery and performed 350 cases. In the presentation, we also show
representative movie of the case of single incision laparoscopic hemi-right colectomy.

Introduction: Prior studies have shown a rate of reoperation ranging from 5.8% to 7.6%
following colorectal surgery with associated increases in morbidity and mortality, however,
the indications for returning to the operating room and procedures performed within 30
days have not been extensively evaluated.
Methods: All patients undergoing colorectal resection at a single institution from 2003
through 2014 were identified. Preoperative and operative factors were evaluated for all
patients. For patients who returned to the operating room, the primary indication was
categorized into one of 18 categories and all procedures performed within 30 days of the
initial operation were indexed. Univariate and multivariate analyses were used to identify
significant correlations between perioperative characteristics and the need for reoperation.
Results: Over the 12-year study period, we identified 2,793 patients who underwent colorectal operations, of which 408 (14.61%) were emergent. A total of 178 (6.73%) patients
returned to the operating room. Fifty-one (12.5%) of the emergent cases required reoperation whereas 127 (5.32%) non-emergent cases required reoperation. On multivariate
analysis (C-statistic 0.69), emergent operation (OR=1.89), recent [10% weight loss
(OR=1.62), corticosteroid use (OR=1.57), and operative duration (OR=1.17 for each hour
[3.0 hours) were independently associated with reoperation whereas independent functional status was found to be protective (OR=0.49). The most common indications for
reoperation are displayed in Table 1, below. Interestingly, 38.76% of patients requiring
reoperation underwent ostomy revision or creation, 20.79% required additional bowel
resection, 15.73% required adhesiolysis, and 12.92% underwent supportive procedures
including gastrostomy, jejunostomy, and tracheostomy.
Conclusions: We have identified the most common indications for returning to the operating room and the specific procedures performed. Given that reoperation is associated with
increased morbidity and mortality, and is a widely utilized quality indicator, this knowledge
will help identify areas where improvement would be most beneficial. It will also allow us
to better inform patients during the informed consent process.
Table 1 Most common indications for reoperation
Primary Indication
for Reoperation

P067
Robotic Surgery for Rectal Cancer in Our Center -First 50
Resection
Chu Matsuda, Katsuki Danno, Susumu Miyazaki, Kazumasa Fujitani,
Masaru Kubota, Masaaki Motoori, Rie Nakatsuka, Masashige
Nishimura, Akihiro Kitagawa, Kazuhiro Iwase, Osaka General
Medical Center
Introduction: Robotic surgery remains a novel technique in the field of colorectal surgery
in Japan. Several small series have examined its safety and feasibility for colorectal surgery.
Our aim was to analyze our entire experience and short-term outcomes with robotic surgery
for rectal cancer since its introduction at our institution. We assert that this approach is
feasible and safe for the patients with rectal cancer.
Material and Methods: This is a retrospective analysis of prospectively gathered data for
all patients who underwent robotic surgery for rectal cancer with the use of single docking
technique of Da Vinci S or Si system between November 2012 and ber 2015. Clinical,
operative and pathologic factors were reviewed and analyzed.
Results: Thirty patients underwent robotic surgery for rectal cancer during the study period.
The locations of tumor were 20 upper rectum, 30 lower rectum. The procedure were as
follow, high anterior resection in 6, low anterior resection in 36, ISR in 3, APR in 5
patients. The procedures were performed successfully in all cases. Mean age was 68 years,
and 64% of the patients were men, and the mean body mass index was 22.4(range,
18.529.4) kg/m2. Median operative duration was 286(190581)minutes. Median console
duration was 147(78441)minutes. Median blood loss was 10(0270)ml. Median postoperative stay was 9 (616) days. Mean harvest lymph node number was 17.0 (537).Surgical
margins were negative in all cases. There was no conversion and anastomotic leakage
occurred in two patients. Morbidity was 18%. There was no mortality postoperatively in
this series.
Conclusion: In early series of the selected patients, this technique appears to be fesible and
safe when performed by surgeons skilled in laparoscopic colorectal surgery. These findings
support the use of a robotic approach for patients requiring rectal surgery.

123

Percent of All
Patients (n=2793)

Percent of Reoperated
Patients (n=178)

Anastomotic Leak

39

1.40%

21.91%

Obstruction

23

0.82%

12.92%

Planned Second Look

21

0.75%

11.80%

Fascial Dehiscence

19

0.68%

10.67%

Bleeding

17

0.61%

9.55%

Surgical Site Infection

12

0.43%

6.74%

P069
Experience of Laparoscopic Peritoneal Lavage for Rectal
Anastomotic Leakage
Daisuke Yamamoto, Hiroyuki Bando, Naohiro Ota, Noriyuki Inaki,
Tetsuji Yamada, Ishikawa Prefectural Central Hospital
Introduction: Rectal anastomotic complications are associated with an increased patient
mortality and morbidity, including the potential need for emergent reoperation and prolonged hospitalization. The gold standard of surgical treatment of rectal anastomotic
leakage is abdominal drainage of collected fluid and stoma formation. Our standard surgery
for colorectal cancer is laparoscopic approach. Not to eliminate the benefit of it, we prefer
to minimally invasive surgery for the leakage.
Methods and Procedures: The previous trocar sites are used for the camera port.
Laparoscopic observation reveals peritonitis caused by rectal anastomotic leakage obviously. Small bowel adhesions and expansion caused by peritonitis are usually mild in early
postoperative period. The abdomen is irrigated with lots of isotonic saline solution. After
adequate drainage of pelvic collection, a drain tube is placed across the anastomosis site of
the pelvic region through the port site. Finally, the loop ileostomy is elevated. Among
467cases who underwent rectal anterior resection or rectal low anterior resection in our
institution from January 2010 to August 2015 (laparotomy 40 cases, and laparoscopic 427
cases),anastomotic leakage was occurred 31 cases (6.6%). 16 of 31 cases were required
reoperation and we performed laparoscopic peritoneal lavage in 7 cases (1.4%) of them. We
investigated those 7 cases retrospectively.
Results: Patients had a median age of 66.7(range 6076) years, and a male to female ratio
was 6:1. Mean operative time was 119 minutes, and average blood loss was 5ml. Three
patients needed polymixin B hemoperfusion. Six cases was discharged from the hospital on
postoperative day in 31.3days average without any complication including surgical site
infection. One patient died of multiple organ failure from sepsis after surgery 92days.
Ileostomy was closed 36month later of all 6 patients.
Conclusion: Laparoscopic peritoneal lavage for rectal anastomotic leakage could help for
diagnosis and reduce the risk of surgical site infection. Consequently this approach should
be considered for the patients with suspect of peritonitis by rectal anastomotic leakage.

Surg Endosc (2016) 30:S325S500

S335

P070

P072

Transvaginal vs Transumbilical Extraction in Colorectal

Resection After Minilaparoscopic Approach or S.I.L.S. TM
Approach

Laparoscopic Versus Open Abdominoperineal Excision: Is There

Any Impact on Patient Quality of Life?

Alerjandra Garci-a Novoa1, Nicolasa Fernandez Soria1, Sergio Builes

Ramirez1, Namibia Sanluis Verdes1, Jose M Munoz2, Gonzalo
Martin, MD3, Antonio Melero4, Jose F Noguera, MD, PhD1, 1Hospital
A Coruna, 2Hospital Son Llatzer, 3Hospital Universitario Son
Espases, 4Consorcio Hsopital General Universitario
Aim: To compare the colorectal extraction trought the vagina vs the umbilical incision for SILS technique
after colorectal laparoscopic resection.
Methods: Prospective clinical series comparing two surgical approaches for colorectal minimally invasive
resection. 24 female patients operated by the same surgeon in the same institution, 12 with minilaparoscopic
approach and transvaginal extraction and 12 with SILSTM transumbilical approach with transumbilical extraction.
For the minilaparospic approach and transvaginal extraction a 3-throcar technique was employed (1x12,
1x11, 1x5 mm transparietal throcars) with transvaginal assistance and extraction trought a posterior vaginal
fornix access.
For the SILSTM an umbilical approach was employed to introduce the decive and after the single port resection
with an internal or external anastomosis the colorectal specimen was extracted trought the umbilicus.
In both cases the specimen was introduced in a plastic bag before the extraction or the surgical field
protected with a plastic bag.
Patients were prospectively followed-up in order to obtain results about the surgical and oncological
outcomes.
Results: In female patients with minilaparoscopy and transvaginal approach no postoperative complications
were found. In all cases a finger dilation of the vaginal incision was needed. We didnt find any problems
related to the extraction or the vaginal closure. No surgical infections, postoperative hernias or oncological
problems were found.
In female patients with Single-Incision-Laparoscopic Surgery trought transumbilical approach we need to
enlarge the umbilical incision in order to perform a safe extraction of the specimen. We found postoperative
problems in three cases (Overall complications, 25%). Two patients with surgical site infection at the
umbilicus and in one case with a late postoperative ventral hernia (Surgical Infection Site, 16.66%, Postoperative Ventral Hernia, 8.33%). In one case we found a parietal recurrence of the colonic adenocarcinoma
at the umbilical incision as an only abdominal wall implant (Port-site metastasis, 8.33%) .
Discussion: In female colorectal laparoscopic resection the transvaginal extraction is better than the transumbilical extraction in order to avoid some complications regarding to the extgraction route. We can find
some problems related to the specimen extraction as the surgical infection site, the postoperative ventral
hernia even the port-site metastasis. To avoid these problems in transumbilical approach, the specimen must
be introduced in a plastic bag and the surgical field covered with a plastic protection.

P071
Methylene Blue Mucosal Staining Improves Polyp Margin
Identification During Tamis. A Validation Study
Aljandro Moreira Grecco, MD, Fernando Dip, MD, Gonzalo Zapata,
MD, Maria Eugenia De Faveri, MD, Luis Sarotto, MD, PhD, Hospital
de Clinicas Buenos Aires
Introduction: Local resection for rectal polyps and early rectal cancer has progressed to become the
standard of care in most institutions. This technique retrieves no fragmented specimen with a high percentage of negative histological limits. In some cases identification of the appropiate resection marging
becomes challenging. We propose the use of methylene blue for mucosal staining to improve intraoperative
lesion identification.
Material y Methods: We present a prospective serie of patients with indication for local resection of rectal a
denomas. Preoperative work up was performed after rectal examination, colonoscopy with biopsy and high
resolution MRI. All patients were submitted to surgery using the trans anal minimally invasive surgery
(TAMIS) platform. The procedures were performed under general anesthesia and in lithotomy position.
After insertion of a gel point path (applied medical) set and neumorectum was created. The rectal mucosa
over the lesion was stained with 1% methylene blue for pathological mucosa delineation. Polyp resection
was performed. Rectal wall defect was closed with interrupted sutures in all cases. For objective surgical
technique validation, a series of videos depicting lesion before and after the methylene blue staining during
tamis was presented to colorectal surgeons, general surgeon, surgical residents and gastroenterologist. After
watching the videos they answered a liker scale survey.
Results: Between February 2013 and April 2015, 8 patients with rectal adenomas were operated.. Mean age
was 63 years (+- 18), mean lesion to anal margin distance was 6.5 cm (+- 2), 28% at the rectal circumference
(+-10) was compromised by the polyp. The entire polyp was resected as non-fragmented specimens and with
negative lateral and deep histological margins. Median follow up was of 7.5 month (318). The survey was
performed to 57 faculties, including 6 colorectal surgeons, 28 general surgeons, 12 surgical residents, and 11
gastroenterologists. Sixty one percent could of the faculties did not identified the margins of the lesions
properly with the white light only. When the dye was used the accuracy of margin detection increased to 100
%.
Conclusion: Methylene blue mucosal vital staining during TAMIS is feasible, easy to perform and improves
lesion border identification.

A Sharpe, D Kamali, A Musbahi, Y Viswanath, A Reddy, James

Cook University Hospital, Middlesbrough UK
Introduction: Laparoscopic surgery has previously demonstrated faster post-operative recovery and fewer
post-operative complications compared with open procedures, expediting faster discharge and a faster return
of patient to normal activities. However, there is little evidence of the long-term quality of life after either
laparoscopic or open abdominoperineal excisions in patients with lower rectal cancer. This study compared
the long-term quality of life (QOL), as well as disease recurrence, in patients after laparoscopic excision
with those after open abdominoperineal excision.
Methods: Patients who underwent either a laparoscopic or open abdominoperineal excision for rectal cancer
between January 2009 and December 2014 at a single unit were recruited for the study. Patient demographics, peri-operative details and follow-up data were recorded and analysed. QOL was determined using
the EORTC QLC-CR30 and QLC-CR29 questionnaires at a minimum of 6 months post-surgery. Chisquared, Fisher Exact and Mann Whitney U tests were used where appropriate. A P value of \0.05 was
considered to be statistically significant.
Results: 45 patients (35 male; mean age 67.4 years; 18 laparoscopic extralevator abdominoperineal excision
ELAPE and 13 laparoscopic standard abdominoperineal excision SAPE versus 5 open ELAPE and 9 open
SAPE) participated in the study. Length of stay (LOS) was shorter in the laparoscopic group (mean LOS 14
days; range 353 days) compared to the open group (mean LOS 19 days; range 857 days). There was one
30 day mortality (laparoscopic SAPE). Circumferential resection margin (CRM) was positive in 2 (4.4%)
patients (both laparoscopic ELAPE who had CRM positivity and adjuvant treatment pre operatively). Two
patients (4.4%) had R1 resections, both of whom had undergone laparoscopic ELAPE. Histological analysis
confirmed a perforated tumour in one and CRM involvement despite adjuvant treatment in the other. Total
recurrence was greater after laparoscopic procedure compared to open procedures (32% versus 15%,
respectively). However this was not statistically significant. There was no significant difference in global
health status between patients with laparoscopic procedure and those with open procedure (70.4 versus 62.5,
respectively). Impotence was the most frequently reported problem encountered by both laparoscopic (83.3)
and open procedure (91.7) patients.
Conclusion: As expected, patients undergoing laparoscopic abdominoperineal excision surgery have a
shorter stay in hospital. Quality of life and rate of recurrence in patients after laparoscopic procedures are
not significantly different from those in patients after open procedures. Impotence remains a significant
problem for all patients and they should be well informed of this risk prior to surgery.

P073
The Feasibility of A Laparoscopic Approach to Re-Operative
Ileoanal J-Pouch Surgery
Sami Chadi, MD, Ido Mizrahi, MD, Steven D Wexner, MD, PhD,
Hon, Cleveland Clinic Florida, Weston, FL
Introduction: Restorative proctocolectomy with ileal J-pouch-anal anastomosis is the current standard of
care for reconstructive surgery in most patients with ulcerative colitis (UC) and familial adenomatous
polyposis (FAP). The current available literature has described successful outcomes for re-operative surgery
with both abdominal and perineal approaches. There are no previous series that have demonstrated the
feasibility of a laparoscopic assisted approach to management of various pouch-related complications
Methods and Procedures: The objective of this single surgeon case series was to establish the feasibility of
a laparoscopic assisted approach in patients presenting to a tertiary care center with pouch-related conditions
necessitating re-operation. Patient demographics and outcomes were retrospectively collected from an IRB
approved prospective database and from IRB approved chart review. All procedures were performed by a
single surgeon with extensive expertise in laparoscopy and pouch-related complications.
Results: Between 2013 and 2015, 9 reoperative pouch procedures were performed on 7 patients (1 FAP, 6
UC) with a mean age of 37 years and BMI of 25kg/m2 (2032). The median time from the prior procedure
was 532 (22438) days. Procedures included laparoscopic assisted pouch revision or repair (7/9), laparoscopic pouch excision (2/9). Mean operative time was 236 (107- 430) minutes. All 9 procedures were
performed with 1 camera and 3 instrument ports. One pre-emptive conversion was made in this series due to
the extent of pelvic fibrosis precluding safe dissection. Most (8/9) procedures were completed with
placement of an intra-abdominal drain. 2 patients developed postoperative pelvic fluid collections, both of
which were successfully drained through percutaneous imaging techniques. Median length of stay was 7
(324) days). All patients with an anastomosis were diverted with a loop ileostomy and stomas were
eventually reversed in all 7 patients.
Conclusion: Reoperative pouch surgery is sometimes necessary to revise or resect a pouch. In cases of
extensive inflammation, a laparoscopic approach may not be feasible. To our knowledge, this is the first
series to demonstrate the utility and feasibility of a laparoscopic approach in patients with pouch-related
complications.

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P074

P076

Single Incision Laparoscopic Colorectal Surgery- Evolution After

750 Cases

Cases in 9 Years of Experience Using Seamguardr (Stapler Line

Reinforcement) in Laparoscopic Colorectal Surgery at Texas
Endosurgery Institute

Deborah S Keller, MS, MD1, Matt Schultzel, DO2, Irlna Tantchou,

MD2, Juan R Flores-Gonzalez, MD1, Sergio Ibarra, MD1, David
A Cardona, MD1, Eric M Haas, MD, FACS, FASCRS3, 3Colorectal
Surgical Associates; Houston Methodist Hospital; University
of Texas Medical Center at Houston, 1Colorectal Surgical Associates,
2
University of Texas Medical Center at Houston
Background: With the drive towards less invasive colorectal surgery to optimize outcomes, there has been a
growing interest in single incision laparoscopic surgery (SILS). Safety and feasibility have been demonstrated, and advantages and applications continue to emerge. Widespread integration of SILS has lagged,
partly due to the perceived technical difficulty, additional learning curve, and patient selection criteria. With
experience, these can be addressed to realize the benefit of SILS. Our goal was to describe the clinical and
financial outcomes in the largest series to date of colorectal SILS.
Methods: Review of a prospective departmental database was performed of a consecutive series of elective
colorectal resections performed via a SILS approach at a single institution. Patient demographics, perioperative variables, postoperative outcomes and hospital costs were evaluated across time for overall outcomes
and trends with SILS. The main outcome measures were the operative time, length of stay (LOS), and
conversion, complication and readmission rates, and costs with SILS.
Results: Between 2009 and 2015, 2 surgeons performed 750 consecutive SILS colorectal cases. The mean
age was 57.0 years(SD14.8), and BMI 28.8kg/m2(SD4.8). The main overall indications for surgery were
colon cancer(26.5%) and diverticulitis(25.3%). Over time, there were sharp increases in use for rectal
cancer(0%, 2009 to 16.9%, 2015) and inflammatory bowel disease(3.6%, 2009 to 20.3%, 2015). To facilitate
pelvic cases, a SILS+1 adaptation was developed in 2012. The main overall procedure performed was a
segmental resection(45.7%). The segmental rate remained stable during the study period, but rates of low
anterior resections increased(0%, 2009 to 23.7%, 2015). The overall conversion rate was 5.7%, but
decreased yearly(9.9%, 2009 to 3.4%, 2015). The mean operative time was 163.3 minutes(SD 67.9) for all
resections, and increased over time with the change in case mix. The mean LOS for all patients was 3.8
days(SD 3.2). The overall rate of complications was 8.0%, readmissions was 4.3%, and unplanned reoperation 1.5%. Complications and readmissions increased with time, as more complex patients and
procedures were performed; reoperations did not rise. The mean total costs were $16,819(SD $12,847), and
remained stable.
Conclusions: In the largest single-institution experience of consecutive SILS colorectal patients, the ability
to optimize resultswithout selection criteria-is seen. With experience, more complex patients and cases can
approached in this fashion without impacting clinical or financial outcomes. Efforts should be aimed at
improving training and utilization so that patients can benefit from this advanced MIS platform.

Morris E Franklin Jr., MD, FACS, Miguel A Hernandez, MD, Jeffrey

L Glass, MD, FACS, Bryson Nicholson, MD, Ekong Uffort, MD,
Texas Endosurgery Institute
Background: Anastomotic leak, bleeding, and stricture are recognized complications with increase morbidity and mortality. The frequency of anastomoses leakage rages from 1% to 24%. The leakage rate is
generally higher for rectal anastomosis (12% 19%) than for colonic anastomoses (11%)(1,2). During
laparoscopic colorectal surgery, the anastomosis may be created intra or extracorporeally. The aim of this
study is to describe our experience, quality of anastomosis, and the low rate of complications in laparoscopic
colorectal anastomosis procedures with SeamguardR, and how it improves the outcomes.
Methods: Retrospective study and collected data of 739 consecutive patients who underwent laparoscopic
colorectal resection and primary anastomosis using SeamguardR since January 2006 to September 2015
were reviewed.
Results: There were no differences in patients demographics, surgical procedure, and anesthesia used.
Complete data was available for 739 patients; 371 (50.3%) female, 368 (49.7%) male. Procedures included
were: 305(41%) right hemicolectomy, 222 (30%) sigmoidectomy, 144 (19.5%) low anterior resection, 29
(4%) subtotal colectomy, 28 (3.8%) left hemicolectomy, and 11 (1.5%) transverse solon resection. The
diagnoses of the patients were: colorectal cancer 290 (39.5%), diverticulitis 168 (23%), polyps 128 (17.7%),
Crohns disease 11 (1.5%), dysmotility 4 (0.5%), rectal prolapse 2 (0.3%), ulcerative colitis 12 (1.7%),
fistula 22(3%), ischemic colitis 11 (1.5%), perforation 28 (3.8%), volvulus 14 (1.9%), and obstruction 49
(6.7%). Median follow-up was 7 months (range 113). Total intracorporeal anastomosis was done in 532
(72%), and hand assisted anastomosis in 207 (28%). There were 3 (0.4%) anastomotic leak detected and
treated intraoperativelly. No strictures, and no bleeding in our early postoperative follow-up period.
Conclusion: The use of SeamguardR at the anastomosis site is feasible and safe, and seems to show a low
rate of stenosis, leaks, bleeding, and better quality of anastomosis.

P077
The Effect of Laparoscopy on the Risk Readmission After
Colorectal Surgery
Miriam Tsao, MD1, Aristithes Doumouras, MD1, Fady Saleh, MD,
MPH2, Dennis Hong, MD, MSc1, 1McMaster University, 2William
Osler Healthcare

P075
Synchronous Anal Melanoma and Colon Adenocarcinoma: Case
Study and Review of Diagnosis and Conduct
Eduardo H Pirolla1, Felipe P Ribeiro2, Fernanda J Pirola1, 1Harvard,
2
UNILUS
Introduction: The aim of this manuscript is to present the clinical manifestations of the disease and to
discuss the diagnosis and treatment methods.Malignant anal melanoma is a rare disorder, reported in
approximately 600 cases in literature, and has never been referred as coexisting with colon adenocarcinoma.
A review of investigation measures and conduct is also presented.
Case Presentation: The authors present the case of a 57-year-old male patient with a positive fecal-occult
blood test, and a previous diagnosis of spoliative anemia. The patient was diagnosed with synchronous anal
melanoma and colon adenocarcinoma.
Conclusion: Synchronous anal melanoma and colon adenocarcinoma are an extremely rare disease and it
has a very poor prognosis. For this reason is fundamental the early diagnosis and treatment. In surgical
treatments all the resections should be sent to anatomopathological examination to try an early diagnosis and
by these measures try to improve patients prognosis. Being a rare disorder there is a lack of studies regarding
how to act in this situation.

123

Introduction: This study evaluated whether laparoscopy was an independent predictor of 30-day readmission after elective surgical resection for colorectal cancer (CRC) in Ontario, Canada. Avoidable
readmission after surgery is a major burden and is common after CRC surgery. This is particularly relevant
in the oncologic population as it results in potential delays to adjuvant therapy. Although laparoscopic CRC
surgery has been gaining popularity its effect on readmission rates has not been well established.
Methods: We performed a population-based cohort study that included all patients who received an elective
colorectal resection for CRC in Ontario, Canada from April 2008 until March 2012. Patient comorbidities,
procedures and demographics were derived from the Canadian Institute for Health Information Discharge
Abstract Database. Socioeconomic status was derived from the Ontario Marginalization Index. Thirty-day
readmission rates were calculated from index procedure. Multivariable logistic regression was used to
examine independent predictors of readmission and included relevant clinical and demographic covariates.
A sensitivity analysis was conducted based on operative time.
Results: Over 4 years, 13,966 procedures were performed with 5,212 (37%) performed laparoscopically.
The 30-day readmission rate was 8.6%, which is similar to other major population-based cohorts. After
multivariate regression, patients who underwent a laparoscopic procedure were 0.80 times as likely to be
readmitted when compared with an open procedure (95% CI 0.70 0.91, p\0.01) (Table 1). This effect
remained after a sensitivity analysis for case complexity that eliminated the longest 25% of open cases OR
0.87 (95% CI 0.75 1.00, p=0.046). Significant predictors of readmission are detailed in Table 1.
Conclusion: Laparoscopy is a significant factor in minimizing readmission rates after surgical resection for
CRC and increasing its utilization should be considered important to any program trying to decrease
readmission rates.

Table 1 .

Surg Endosc (2016) 30:S325S500

S337

P078

P080

Colorectal Anastomotic Leakage in Laparoscopic Low Anterior

Resection: Aspects of Prevention and Technical Tips

The Effect of Distance from an MIS Training Center

on the Utlization of Laparoscopy for Colorectal Cancer

Toshimasa Yatsuoka1, Junichi Tanaka1, Takahiro Umemoto1, Sumito

Sato1, Yoji Nishimura2, Yoshiyuki Kawashima2, Hirohiko
Sakamoto2,
1
Showa University Fujigaoka Hospital, 2Saitama Cancer Center

Aristithes Doumouras, MD1, Fady Saleh, MD, MPH2, Miriam Tsao,

MD1, Dennis Hong, MD, MSc1,
1
McMaster University, 2William Osler Healthcare

Aims: Low rectal anastomosis with the double-stapling technique (DST) was reported by Knight and Griffen in 1980. Despite of the recent advances of stapling devices,
anastomotic leak is one of the most dangerous and feared surgical complications after low anterior resection (LAR). The development of a leak is known to be associated
with local recurrence and worse prognosis after a curative resection for rectal cancer. The aim of this study is to address technical tips for preventing anastomotic leakage
after laparoscopic low anterior resection (Lap LAR) and review the clinical outcome of our experiences.
Methods: We completely mobilize the rectum to the pelvic bottom due to perform a safe transection of the lower rectum. The lower rectal segment is transected and
closed horizontally using a single-fire cartridge with a flexible linear stapler. Performing the DST, the center rod of circular stapler is pierced through one third of the left
end of the rectum stapler line to eliminate the dog-ear on the left side (eliminating the left lateral intersection). We make the additional sutures to eliminate rigt-sided dogear in DST anastomosis. We use the routine intra-operative colonoscopy (IOC) to visualize anastomotic bleeding and anastomotic leakage. A transanal drainage tube is
placed through the anastomosis.
Results: Between January 2007 and March 2015,1446 patients undergoing anterior resection for rectal cancer was done. Conventionl open low anterior resection (Open
LAR) was performed in 250 patients and Lap LAR was done in 28 patients. In Open LAR group anastomotic leakage occurred in 18 patients (6.9%) and in Lap LAR
group anastomotic leakage occurred in one patients (3.5%).
Conclusion: Our techniques may be safe and effective means of reducing the occurrence of anastomotic leakage in laparoscopic low anterior resection. Making further risk
reduction in colorectal anastomosis, a larger-scale prospective randomized study is necessary for further clarification of this issue in laparoscopic surgery.

Introduction: We hypothesized that distance from a minimally invasive surgery (MIS) fellowship training site had a significant effect on the utilization of laparoscopy for
rectal cancer at the neighborhood level.
Methods: This was a population-based study of all patients aged [18 who received a low anterior resection for rectal cancer from April 2008 until March 2012 in the
province of Ontario, Canada. The main outcome of interest was neighborhood rate of laparoscopy, split into tertiles (high, medium and low). Data was derived from the
Canadian Institute for Health Information Discharge Abstract Database. Neighborhood socioeconomic status (SES), rural status and distance from MIS fellowship
training center were the main exposures. Ordinal logistic regression was utilized to compare odds of being in the highest utilization group to the middle and low utilization
groups. A patient level multi-level mixed effects regression model was created as a sensitivity analysis.
Results: Overall, 3,238 patients underwent low anterior resection for rectal cancer within 470 neighborhoods. Laparoscopy rates were 21.2%. More than a third of
neighborhoods had laparoscopy rates of 0% which comprised the lowest utilization group. In the multivariate analysis, for each increase in 100 kilometers from an MIS
fellowship training facility, a neighborhood was 0.85 times as likely to be in the highest utilization group compared to the middle and lowest groups (95% CI: 0.77 - 0.93;
P-value \0.01) (Table 1 and Fig. 1). Additionally, for each increase in SES quintile, from lowest to highest, a neighborhood was 1.15 times as likely to be in the highest
utilization group (95% CI: 1.011.30; P-value 0.03). These remained significant after sensitivity analysis.
Conclusion: This study identified an unequal utilization of laparoscopy for rectal cancer within Ontario. Distance from an MIS fellowship training site was associated
with lower odds of being in the high utilization group thus creating a clear disparity in healthcare delivery.

Table 1

P079
Laparoscopic Surgery to Locally Advance Colon Cancer Invading
to Adjacent Urinary Structures
Yosuke Fukunaga, MD, PhD, Masashi Ueno, Satoshi Nagayama,
YoshiyaT Fujimoto, Tsuyoshi Konishi, Takashi Akiyoshi, Toshiya
Nagasaki, Jun Nagata, Yukiharu Hiyoshi, Hisanori Miki, Atsushi
Ogura, Shunsuke Hamasaki, Hiromichi Fukuoka, Yuzo Fukuda,
Cancer Institute Hospital
While recent development and penetration of the laparoscopic colorectal surgery, magnification of high quality optics plays an important role to achieve high level of
curability as well as less invasiveness. We retrospectively investigated feasibility of laparoscopic surgery to locally advance colon cancer invading to adjacent urinary
structures.
Nineteen cases of colon cancer invading to adjacent urinary structures by preoperative diagnostic modalities were treated by laparoscopic operation since 2010 in our
hospital. The patients in whom the primary tumor invaded to full thickness of the urinary bladder underwent lymph node dissection and colonic mobilization in
laparoscopically and partial resection of the urinary bladder in direct vision via Phannestiel transverse skin incision just above the pubic bonne. In patients in whom the
both urinary orifices were invaded, total cystectomy associated with the primary cancer was performed in laparoscopically. In patients in whom the ureter was invaded by
the primary cancer, reconstruction of the ureter was performed in end-to-end anastomosis or interposition of the ileum in laparoscopically.
Results: There were 2 open conversions (12%). The median operation time and estimated blood loss was 345 min and 85 g, respectively. There were 5 postoperative
complications (wound infection in 2, small bowel obstruction in 2, and urinary retention in 1 case). No mortality was encountered. All 19 cases were pathologically
proved of negative for cancer on the excisional surface of the specimen.
Conclusions: A surgeon should obtain urological specific techniques in laparoscopically when treating to locally advance colon cancer invading to the adjacent urinary
structures. Once they know how to mobilize the urinary bladder and how to reconstruct the ureter via laparoscopy, this radical laparoscopic operation may be feasible on
the basis of less blood loss with less postoperative mobility.

Fig. 1 .

P081
Tumor Localization Using Carbon Nanoparticles
for Laparoscopic Colectomy
Jun Yan1, Yu Zheng1, Zhangyuanzhu Liu1, Xiufeng Wu2, Fangqing Xue1,
Xiaoling Zheng1, Wenju Liu1, Hong Shi2, Wei Gong1, Guoxin Li1,
1
Department of General Surgery, Nanfang Hospital, Southern Medical
University, Guangzhou, Guangdong, 510515, P.R.China, 2Department
of Surgery, Fujian Provincial Tumor Hospital, Teaching Hospital of Fujian
Medical University, Fuzhou, Fujian, 350014, P.R.China
Background:Accurate tumor localization is critical to performing laparoscopic colectomy which is lack of tactile sensation. The purpose of this study was to evaluate the feasibility and
safety of using carbon nanoparticles to localize non-palpable tumor for laparoscopic colectomy, compared with intra-operative colonoscopy.
Methods: A prospective study was performed between July 2012 and September 2015. Inclusion criteria included T13 colon cancer, big adenoma or polyp unsuitable for
endoscopic resection, multiple colorectal tumors, and cancer complete or partial response after neoadjuvant therapy. Exclusion criteria included T4 colon cancer, planned local
excision, previous abdominal surgery, and emergency case with bleeding or obstruction or perforation. Sixty patients were enrolled in this study and divided into carbon nanoparticles
group (30 cases) and intra-operative colonoscopy group (30 cases). One milliliter carbon nanoparticles suspension, which is approved by Chinese Food and Drug Administration, was
endoscopically injected into the submucosal layer at four points around the tumor one day before surgery in carbon nanoparticles group. Laparoscopic colectomy was performed.
Patients perioperative clinical and pathological data were compared between two groups.
Results: Both groups were comparable in age, sex distribution, American Society of Anesthesiologists (ASA) score, body mass index (BMI), technique performed, tumor
size, and tumor location. In carbon nanoparticles group, tumor area was black-dyed by carbon nanoparticles and easily identified during laparoscopic colectomy. No
patient had any side effects of carbon nanoparticles in this study. All tumors were correctly localized in two groups. However, the operative time was significant short and
convertion rate was significant low in carbon nanoparticles group, compared with intra-operative colonoscopy group. Moreover, more lymph nodes were harvested in
carbon nanoparticles group. There were no differences between groups regarding hospital stay and postoperative complication rates.
Conclusions: It is feasible to use carbon nanoparticles to localize non-palpable tumor for laparoscopic colectomy. Carbon nanoparticles suspension is safe for submucosal injection.

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P082

P084

Laparoscopic Pelvic Organ Prolapse Suspension

with Transvaginal Mesh Fixation

Perfact Procedure (Proximal Superficial Cauterization Around

the Internal Opening, Emptying Regularly of Fistula Tracts
and Curettage of Tracts): A New Minimally Invasive Simple
Concept to Treat Highly Complex Anal Fistula

Seung Hyun Baek, MD, NahmGun Oh, Phd,

Pusan National University Hospital
Background: Laparoscopic pelvic organ prolapse suspension is known as effective and safe technique for
rectocele. The surgery is performed only laparoscopic approach. The implant mesh fixed by laparoscopic
suturing.
Purpose: Laparoscopic access alone requires skills for mesh fixation suturing . The authors propose hybrid
technique by using transvaginal approach for mesh fixation.
Technique: At the lithotomy position, under vaginal skin incision, prolene mesh is inserted. After
transvaginal fixation, the grasper is inserted through laparoscopic port for unfolding mesh. The both tail of
mesh is fixed under skin by trocar opening.
Methods: From 2013 to 2014, A total of 10 patients underwent pelvic reconstruction of Laparoscopic POPS
/c transvaginal mesh fixation. This study was conducted at a single institution.
Results: There was no significant complication of wound infection, postoperative pain and co-morbidity.
There was no recurrence after postoperative 60days.
Conclusions: Laparoscopic pelvic organ suspension with transvaginal mesh fixation is alternative technique
for treatment rectocele

Pankaj Garg, Dr1, Pratiksha Singh, Dr1, Devika Singh2, Mohinder K

Garg, Prof3, 1Garg Fistula Research Institute, Panchkula, India,
2
Boston University, Boston, 3BPS Government Medical College
for women, Khanpur kalan, Haryana, India
Introduction: To check the efficacy of Perfact (Proximal superficial cauterization around the internal
opening, emptying regularly of fistula tracts and curettage of tracts): procedure to treat highly complex
fistula-in-ano
Methods: Perfact procedure entails two steps- superficial cauterization of mucosa at and around the internal
opening & keeping all the tracts clean. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open so as to heal/close the internal opening by granulation
tissue(secondary intention). Objective incontinence scoring was done preoperatively & postoperatively.
Results: After getting approval from ethics committee of the hospital, this procedure PERFACT (Proximal
superficial cauterization around internal opening, emptying regularly of fistula tracts in post operative period
and curettage of tracts) - was performed in 122 patients. All were complex fistula intersphincteric with
multiple extensions (Parks type-1, James type-2) in 5, transpshincteric (Parks type-2, James type-3 &4) in
104 and supralevator fistula (Parks type-3, James type-5) in 13 patients. There were multiple tracts in 65.5%
(80/122), recurrent fistula in 58.1% (71/122), horseshoe tracts in 49 (40.1%), abscess in 43 (35.2%),
supralevator in 13 (10.7%) and anterior fistulae in 10 (8.2%) female patients. M/F was 102/20 and average
age was 42.6 11.8 years. The median follow up was 12 months (522 months). Sixteen patients were
excluded (lost to follow-up/ non-adherence to protocol). The healing rate after the first operation was 70.8%
(75/106). Twelve out of 31 non-healed patients were operated again. Eight out of these got alright. So the
overall healing rate was 78.3% (83/106). All patients were discharged from the hospital within 24 hours of
admission. There was no significant change in incontinence scores.
Conclusions: Perfact procedure is a minimally invasive and novel method to cure complex fistula-in-ano. It
is simple and economical It is associated with little pain, least morbidity and minimal risk of incontinence as
both the anal sphincters are completely preserved. It is quite effective in complex fistula cases (overall
success rate of upto 78.3%) where other methods do not have a high success rate like horseshoe fistula,
fistula with multiple tracts, recurrent fistula and fistula with supralevator extension. Perfact procedure is also
quite successful in cases where internal opening cannot be localized and presenting with perianal/ischiorectal abscess where it can be done as a definitive procedure on initial presentation.

P085
P083
Totally Laparoscopic Versus Laparoscopic Assisted Left
Colectomy for Cancer: A Retrospective Review
Forat Swaid, MD, Gideon Sroka, MD, Hussam Madi, MD, Dan
Shteinberg, MD, Mustafa Somri, Prof, Ibrahim Matter,
Bnai-Zion Medical Center
Background: Laparoscopic left colectomy (LLC) became the standard of care for treating distal transverse
and descending colon cancer in many centers. Most centers use laparoscopic assisted colectomy with
extracorporeal anstomosis (LAC/EA). A totally laparoscopic colectomy with intracorporeal anastomosis
(TLC/IA) has been proposed. The purpose of our study is to compare these two techniques.
Methods: A series of 52 patients undergoing LLC for left-sided colon cancer was retrospectively evaluated.
Thirty three patients underwent TLC/IA, and 19 underwent LAC/EA. The following data was collected:
gender, age, body mass index (BMI), American Society of Anesthesiologists risk class (ASA), operation
duration, conversion to laparotomy, intra-operative complications, postoperative complications, postoperative course (duration of stay, time to first flatus), number of excised lymph nodes, readmission, and
reoperation rates. Data was prospectively recorded in a colorectal cancer database and retrospectively
analyzed.
Results: The only demographic parameter that differed significantly between the groups was age
(64.212.4 years for the TLC/IA group, vs. 72.72.1 years for LAC/EA, p=0.0116). The mini-laparotomy
incision was significantly shorter in the TLC/IA than in the LAC/EA group (5.80.9 cm vs. 8.20.9 cm,
respectively, p\0.00001). Hospital stay duration was shorter in the TLC/IA group (4.2 1.2 vs. 6.31.9,
p=0.0001). The average number of harvested lymph nodes did not differ significantly between the groups
(12.95.7 in TLC/IA vs. 11.24.2 in LAC/EA, p=0.2546). No significant differences between the groups
were observed in any other perioperative or surgical outcome parameters.
Conclusions: TLC/IA in LLC for the treatment of left colon cancer is technically feasible and can be
performed with a low complication rate, favorable cosmetics, and possibly shorter hospital stay, without
significantly lengthening operative duration or compromising oncologic radicality principles. Although
further prospective randomized studies are needed to determine its role and limitations, we encourage using
it as an alternative to LAC/EA in LLC.

123

Laparoscopic Complete Mesocolic Excision Conducted

by Combining Medial and Cranial Approaches for Transvers
Colon Cancer
Shinichiro Mori, Yoshiaki Kita, Kenji Baba, Masayuki Yanagi,
Yusuke Tsuruta, Takako Tanaka, Yuko Mataki, Kosei Maemura,
Yasuto Uchikado, Shoji Natsugoe, Department of Digestive Surgery,
Breast and Thyroid Surgery, Graduate School of Medicine,
Kagoshima
Objective: We have evaluated the safety and feasibility of laparoscopic complete mesocolic excision
(CME) conducted by combining medial and cranial (MC) approaches with lymph node dissection around the
gastrocolic trunk (GCT) and the middle colic vessels for transvers colon cancer.
Patients and Methods: We retrospectively analyzed 18 consecutive patients with transverse colon cancer
who had undergone laparoscopic complete mesocolic excision (CME) via combined medial and cranial
(MC) approaches between July 2009 and June 2015 by studying video recordings of the procedure and
assessing operative data, pathological findings, length of bowel resected, complications, and length of
hospital stay.
Surgical Procedure: The medial approach was performed by dissecting the peritoneum behind the the
ileocolic vessels and separating between mesocolon and fusion fascia. The ileocolic vessels were then
divided at their roots. Lymph node dissection proceeded along the SMV to expose the middle colic artery
(MCA) and its branches. The MCA was identified arising from the SMA and these vessels were severed at
the roots of their branches. Subsequently, the GCT and its branches were carefully and sufficiently exposed
from the medial side. A wide separation of embryological tissue plane between the pancreatic head and
transverse mesocolon was performed, and then the separation of the mesofascial plane was also performed.
In patients with left transverse colon cancer, dissection of the peritoneum behind the inferior mesenteric vein
was followed by performing mesofascial separation between the descending mesocolon and fusion fascia,
and mobilizing the splenic flexure.
Next, a cranial approach was performed by dissecting the greater omentum, after which the fusion fascia
between the omentum and transverse mesocolon was detached, exposing the SMV, and the hepatic flexure
was mobilized in continuity. The accessory middle colic veins were carefully dissected with 3dimensional
identification of the GCT via both of the MC approaches.
Results: Sixteen and two patients graded mesocolic and intra-mesocolic plane, respectively. Nine, two, four,
and three patients had T1, T2, T3, and T4a tumors, respectively. The median number of lymph nodes
retrieved was 17.2, no lymph node metastasis being identified. The mean length of large bowel resected was
23.3 cm. The mean operative time and intraoperative blood loss were 272 min and 41 mL, respectively. No
intraoperative complications occurred in any patient. Two patients had postoperative complications. The
median postoperative hospital stay was 15 days.
Conclusions: Laparoscopic CME via combined MC approaches is a safe and feasible procedure for
transverse colon cancer.

Surg Endosc (2016) 30:S325S500

S339

P086

P088

Social Determinants of Health Do Not Predict Emergent

Operation for Diverticulitis

The Feasibility of a Laparoscopic Approach to Complex

Colovesical and Enterovesical Fistulas

Britney L Corey, MD, Lauren E Goss, Allison A Gullick, MPH,

Daniel I Chu, MD, Melanie S Morris, MD, Jayleen M Grams, MD,
PhD, University of Alabama at Birmingham

Daniel Bekele, MD, Sami Chadi, MD, Giovanna Dasilva, MD, Steven
D Wexner, MD, PhD, Hon, Cleveland Clinic Florida, Weston, FL

Introduction: Social determinants of health (SDOH) have been associated with disparities in access to care and treatment-decisions.
Emergent management of diverticular disease may be related to variations in these factors. We hypothesized that SDOH are a risk
factor for emergent treatment of diverticular disease.
Methods: A retrospective review was performed on all patients who underwent an operation for diverticular disease between
January 1, 2009 and December 31, 2014 at a tertiary-care academic institution. SDOH variables included marital status, insurance,
and socioeconomic status (SES). SES was determined using 6 measures compared to national census data to generate a neighborhood summary Z score (Table 1). Patients were stratified by emergent versus nonemergent operation. Multivariate analysis was
performed of all possible covariates including SDOH. Significance was determined as p-value B0.05.
Results: Of the 182 patients who underwent an operation for diverticulitis, 54 (29.8%) were emergent and 128 (70.2%) were nonemergent. There were no differences between groups for age or marital status. Although there was a trend, there was no significant
difference based on race (p=0.055). Compared to non-emergent patients, emergent patients were more likely to be male (59.3 vs
39.8%, p=0.016) and have non-private insurance (61.1 vs 36.7%, p=0.003). Distance to hospital was significantly greater for nonemergent patients compared to emergent patients (63.8 vs 43.0 miles, p=0.035). There was no significant difference between groups
based on summary Z score. On multivariate analysis, marital status, insurance status, and SES score did not predict an emergent
operation.
Conclusion: SDOH did not predict an increased likelihood of emergent operation for diverticular disease. Emergent operation may
be based upon the severity of disease and affected less by access to care or delay in diagnosis. Further studies are necessary to define
factors predicting emergency surgery for diverticulitis

Introduction: Despite the advantages of laparoscopy, few reports have discussed the practicality of a laparoscopic approach to
complex fistulizing disease. The objective of this study was to demonstrate the feasibility of a laparoscopic approach to the
management of enterovesical (EV)/colovesical (CV) fistulas.
Methods and Procedures: An IRB approved prospective surgical database was queried for all patients with a diagnosis of EV or
CV fistula with a laparoscopic approach. Demographic data was tabulated and compared. A priori definitions were created for the
type of laparoscopic approach as well as conversions. Cases were identified with a combination of CPT/ICD codes. Malignant cases
were excluded given the need for an en bloc resection.
Results: 39 patients were identified (70% male, mean age 61 years, mean BMI 27kg/m2). 70% of patients presented with a chronic
urinary tract infection with 61% describing pneumaturia. Complicated diverticulitis represented 82% of patients compared to
Crohns disease (18%). Pre-operative CT was performed, most commonly revealing intravesical air (48%). 75% of operations began
laparoscopically (LAP) while the others (25%) were started with hand-assist devices (HALS). 57% of LAP operations were
converted to an open infraumbilical incision for the safety of the dissection. Three procedures (7.6%) were converted to a HALS
technique for similar reasons. Thirty-two (83%) patients had a primary anastomosis with no diversion (67% sigmoid; 13% ileocolic)
while 10% had a diverting loop ileostomy that was later reversed and 8% had an end stoma (2 end colostomy and 1 end ileostomy
following total abdominal colectomy). The average operative time was 231 minutes with a mean blood loss of 187cc. 59% of
patients had no intervention for the bladder opening, mostly because of the non-compliant inflammatory reaction. The median length
of stay was 6 days with a post-operative cystogram performed at a median of 6 (320) days with the Foley removed at a median of
6.5 (330) days. The readmission rate for this cohort was 10% (2 surgical site infection, 1 pelvic abscess, 1 stoma-related
dehydration). One ureteric injury occurred in this series, in a patient with an anastomotic leak.
Conclusion: Despite a high conversion rate in this series, we have demonstrated that a primarily laparoscopic approach to fistulizing
bladder disease appears to be safe. Given the nature of conversions, surgeons are aware of when the limits of their laparoscopic skills
have reached the limits of safety necessitating conversion.

Table 1 Patient factors

P089
Improving Surgical Fields Management During Davinci XI Low
Anterior Resection (R-LAR): A Proposal of a New Ports
Placement
Giuseppe Spinoglio, MD, Paolo Bellora, MD, PhD, Manuela Monni,
MD, Luca Portigliotti, MD, Maggiore della Carita Hospital Novara - Italy

P087
Utility of 3D-CT Angiography for the Preoperative Examination
of Laproscopic Surgery for Transverse Colon Cancer
Shuji Saito, MD, Hitomi Takaishi, MD, Ryo Otsuka, MD, Ryoichi
Hirayama, MD, Yokohama Shin-Midori General Hospital
Introduction: The arterial divergence form and distribution flowing into the transverse colon are highly individualized. Under the
Japanese D3 lymph node dissection method for transverse colon cancer, we dissect along and preserve the common trunk of the
middle colic artery (MCA) and ligate and divide a root of the right branch or the left branch; however, the length of the common
trunk of the MCA varies on an individual basis. We occasionally encounter an anomalous artery associated with the transverse
colon. One of them is the so-called accessory left colic artery (A-LCA), which originates from the superior mesenteric artery (SMA),
runs between the MCA left branch and left colic artery, and supplies the splenic flexure. The frequency of the A-LCA is not
described in anatomical scholarly books. It may be difficult to confirm arterial divergence laparoscopically during an operation,
which can prolong the operative time. The aim of this study was to examine the arterial divergence form flowing into the transverse
colon using preoperative 3D-CT angiography (3D-CTA).
Methods and Procedures: We confirmed the arterial run flowing into the transverse colon using preoperative 3D-CTA for 52 colon
cancer cases. We confirmed the divergence form of the right branch and left branch of the MCA and measured the length of the
common trunk. We defined arteries which diverged from the SMA near or on the proximal side of the first jejunal artery or the celiac
artery (CA) and flowed into the colon of the spleen flexure to be A-LCA. We additionally confirmed the presence or absence of the
A-LCA using preoperative 3D-CTA for 108 colon cancer cases.
Results: Fifty-two MCAs were observed in all cases; in nine patients (17%) there was independent divergence of the right branch
and left branch without forming a common trunk. In 43 patients that formed a common trunk, the mean length of the common trunk
was 3.1 1.9 (0.89.7) cm. We recognized A-LCA in 39% (42/108) of all cases, and four A-LCAs diverged from the CA.
Conclusion: Confirming the course of the feeding artery preoperatively using 3D-CTA is an essential preoperative examination for
laparoscopic surgery in order to perform precise, minute dissection of the transverse colon cancer.

Introduction: We propose a new robotic instruments placement to improve surgical fields management during R-LAR.
Methods and Procedures: After having induced pneumoperitoneum (PNP) through Veress needle apposition in the left
hypochondrium, an oblique line between left colonic flexure and pelvic bone is drawn. Airseal is introduced to maintain PNP, then
four 8 mm robotic ports (P) are placed on a second parallel line, drawn 1015 cm at the right side of the first. P placement is as
follows: P1: 24 cm from the xyphoid and 02 cm at the left of the median line; P 234: equidistant 68 cm from P1 and one from
each other, P4 being usually placed at 24 cm from the right iliac spine. Airseal dispositive lays 78 cm at the right side of P3 and 2
cm below. Patient is slightly turned on the right in Trendelemburg position. The robotic cart is approached to operating table and P2
is attached to arm 2, to target robotic camera on sigmoid colon. Once the target is completed we dock all the arms.
The first surgical step is vessel dissection and cutting (IMA and IMV): we place the camera in P3. We dissect the descending and
sigmoid mesocolon between the two shits of the Toldt fascia in avascular plain until the lateral abdominal wall and the colonparietal attachment. We then expose, in the same median to lateral way, the inferior bord of the pancreas and the gubernaculum
lienis. We incise from below to above the inferior fold of the transverse mesocolon at the bord of the pancreas and we detache it until
the pancreas tail. We place the camera in P2 and we detached the descending colon from the parietal wall, the splenic flexure and the
epiploon from the colon. We start with the pelvic dissection with the same instruments placement (camera P2) using the lower
instruments (P3 and P4) to retract and dissect. The main difference from the dVSi is that we have two instruments in the right
abdomen and we use pelvic retractor from the right.
Conclusions: This placement, in our experience, allows to work better in splenic flexure mobilization and pelvic dissection with
single docking.

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P090

P092

Usefulness of Blood Flow Evaluation by Indocyanine Green

Fluorescent System in Laparoscopic Colectomy

Laparoscopic Total Mesorectal Excision for Rectal Cancer

by Using a New Device Lock-ARM Replacing an Assistants
Roles

Jun Higashijima, PhD, Mitsuo Shimada, Professor, Takashi Iwata,

PhD, Kozo Yoshikawa, PhD, Toshihiro Nakao, PhD, Masaaki Nishi,
PhD, Hideya Kashihara, PhD, Chie Takasu, PhD, Department
of Surgery, Tokushima University, Japan
Introduction: Insufficient blood flow is the major cause of anastomotic leakage. So intraoperative blood
flow evaluation is very important. Indocyanine green (ICG) fluorescent system can perform intraoperative
bloodflow evaluation in various organs. In this report, we show the clinical usefulness of indocyanine green
(ICG) fluorescent system in laparoscopic colectomy.
Methods: 1. Usefulness of ICG system in anterior resection : Rectal cancer patients (n=67) who underwent
laparoscopic anterior resection were included. Bloodflow of the stumps of the colon were evaluated using
ICG fluorescent system. After resection of rectum, 7.5mg of ICG was administered, and the blood flow of
oral stump was evaluated by measuring fluorescent time. Relationship between the time until recognition of
blood flow at the stump and anastomotic leakage was investigated. And to evaluate the both stump in
laparoscopic anterior resection, laparoscopic ICG fluorescent system was used. Fluorsecnt time of both
stumps were measured and the blood flow of both stumps were evaluated.
Usefulness of ICG fluorescent system in other operation.
Results: 1. Three of sixty seven patients (4.5%) suffered anastomotic leakage. The fluorescent time of two
patients were over sixty seconds and in one patient, fluorescent was not recognized. Under sixty seconds
cases, patients suffered no anastomotic leakage. In eighty seconds case, we could avoid anastomotic leakage
by additional resection of the colon with low blood flow. And in laparoscopic ICG fluorescent system
evaluation, fluorescent time of both stumps were all under sixty seconds and there was no leakage.
2. Laparoscopic ICG fluorescence system is also useful in other operation. Laparoscopic ICG system can
evaluate the bloodflow of intestine and other organs in abdominal cavity, so this system can be used widely
in various operation. For example, our one interesting case, in patient with advanced cancer in SD junction,
the oral colon was ischemic after resection of the tumor and we could avoid anastomotic leakage. Like this
case, laparoscopic ICG system is usefull not only in anterior resection but also in other operation.
Conclusion: ICG fluorescent system is useful for evaluating blood flow, and avoiding anastomotic leakage
in laparoscopic colectomy.

Akihiro Kondo, MD, Masaaki Ito, MD, Yuji Nishizawa, MD, Rie
Matsunaga, MD, Takeshi Sasaki, MD, Akihiro Kobayashi, MD,
Division of Colorectal Surgery, National Cancer Center Hospital East
INTRODUCTION: An assistant is required to hold surgical forceps and maintain the same position for
long time during laparoscopic surgery. These assistants roles could be replaced by some surgical devices
having the functions as holding or fixing the surgical forceps. We developed a new device as replacer of
assistants roles, which termed a Lock-Arm, developed by collaboration with Japanese company, SYSTEM JP. The purpose of this study is to show how to use this new device in laparoscopic total mesorectal
excision (TME) and to assess the tips, surgical merits and safety by using this one.
Methods and Procedures: We performed laparoscopic TME by use of this device in 37 patients with low
rectal cancer. The Lock-Arm could be used not for holding endoscopy during laparoscopic surgery but for
controlling an assistants forceps. The Lock-Arm is shaped with multiple joint, and we can easily move
these forceps to every direction surgeon want to and fix them at any position by controlling a foot pedal
without using surgeons hand. Especially in laparoscopic TME, the Lock-Arm could play very important
roles controlling the rectal traction through the suprapubic port site. Good surgical exposures during
laparoscopic TME could be achieved by fixing and making the proper traction of the rectum with surgical
forceps controlled by the Lock-Arm. This also provided stable fixation and rapid movement in a surgical
field and did not interrupt the surgeons forceps during the procedure.
Results: Of 37 patients with low rectal cancer, 21 were men and 16 were women. The median age was 59
years (range, 3580 years), median operating time was 260 minutes (range, 133500 minutes) and median
blood loss was 40 mL (range, 5818 mL). No adverse events relating the use of this device were found in
laparoscopic TME.
Conclusion: The Lock-Arm could be used safely and replace the assistants roles such as quick
movement and stable fixation of the rectum in laparoscopic TME.

P091
P093
Laparoscopic vs. Open Metastatic Lateral Lymphadenectomy
for Rectal Cancer
Shigeki Yamaguchi, MD, Toshimasa Ishii, MD, Jo Tashiro, MD,
Hiroka Kondo, MD, Kiyoka Hara, Masayasu Aikawa, Mitsuo
Miyazawa, Saitama medical University Interntional Medical Center
Purpose: Resection of metastatic lateral lymph node for rectal cancer is controversial in western countries.
In this study long term results was assessed for lateral lymphadenectomy for lateral node positive patients,
also assessed between laparoscopic (lap) and open resection.
Method: Since April 2007 to March 2014, curative resection was performed for 324 lower (extraperitoneal)
rectal cancer patients including 25 lateral node positive patients (7.7%). Laparoscopic and open resections
with metastatic lateral lymphadenectomy were performed for 6 and 19 patients, respectively. Only 3 patients
underwent preoperative chemoradiation to obtain sufficient resection margin.
Results: Mean observation was 1618 days, 5 year cumulative survival was 79.0% and 3 year relapse free
survival (RFS) was 58.7%. Recurrence was observed in 12 patients (48%), recurrent sites were; locoregional 7, lung 5, liver 3, paraaortic 4. According to lateral node positive number, recurrent rates were; 1=
28.6% (4/14), 2= 60% (3/5), 3 or more= 83% (5/6). Mean operative time and blood loss were 327 minutes,
85g in lap and 349 minutes, 587g in open group. Median postoperative hospital stay was 11 in lap and 12 in
open. 3 year RFS was 83% in lap and 42% in open (P=0.09).
Conclusion: Lateral lymphadenectomy for node positive rectal cancer patients was effective and laparoscopic resection was feasible for selective patients.

123

Colorectal Cancer in Young Adults in Southern Part of Pakistan

(Laparoscopic Management and Outcome at Liaquat University
Hospital Hyderabad
ArshadHussain Abro, Dr, Abdul Aziz Laghari, Prof, LUMHS
PAKISTAN
Objective: To evaluate the laparoscopic management and outcome of colorectal cancer in young adults in
Southern part of Pakistan presented at Liaquat University Hospital Hyderabad / Jamshoro.
Patients and Methods: The descriptive case series study was conducted in department of surgery at Liaquat
University Hospital Hyderabad. All the patients with 1030 years of age of either gender presented with
history of abdominal pain and lump, constipation, anorexia and bleeding per rectum, weight loss were
included in the study and were further explored for colorectal carcinoma by histopathology. The frequency
and percentage was calculated for categorical variables and mean SD was calculated for numerical
variables. As this was descriptive case series so there was no any statistical test of significance was applied.
Results: During five year study period, total one hundred patients diagnosed as colorectal carcinoma with
means age 20.643.43 (SD). Of 100, 72 were males and 46 were females while the common causes
identified were radiation, low fiber diet and excessive smoking. The most common tumor detected was
adenocarcinoma in 80 patients while the squamous cell carcinoma was most common tumor observed in
anal canal in 20 patients. The management options applied were laparoscopic anterior resection in 60
patients, laparoscopic abdominal perineal resection in 25 patients and laparoscopic left and right hemicolectomies in 15 patients. Regarding outcome all patients underwent for chemotherapy and radiotherapy,
recurrence occurred in 15 patients on follow up visits while the mortality was 10% during follow up.
Conclusion: It has been concluded that colorectal carcinoma is becoming common cancer in young adults;
the management options included laparoscopic anterior resection, laparoscopic abdominal perineal rsection
and laparoscopic left / right hemicoloectomies.

Surg Endosc (2016) 30:S325S500

S341

P094

P096

Feasibility and Safety of Intraoperative Colonoscopy After

Segmental Colectomy and Primary Anastomosis for Partial
Colonic Obstruction

A Rare Case of Primary Leiomyosarcoma of the Sigmoid Colon

and Urothelial Carcinoma of the Bladder in a Crohns Patient

Ray S King, MD, PhD, Erika Simmerman, DO, P B Ham, MD,

Zachary Klaassen, MD, Vendie Hooks, MD, Medical College
of Georgia
Background: Patients presenting with endoscopically-proven partially obstructing colon lesions requiring
segmental colectomy, who were unable to complete their pre-operative colonoscopy due to the inability to
pass the colonoscope beyond the lesion, may benefit from intraoperative colonoscopy after primary anastomosis for a more timely and accurate diagnosis of synchronous lesions.
Objective: The aim of this study is to demonstrate the feasibility and safety of intra-operative completion
colonoscopy after primary anastomosis following segmental colectomy in the management of patients who
received incomplete preoperative colonoscopy secondary to partial obstruction.
Design and Setting: This was a retrospective cohort study over a 5-year period of 168 patients undergoing
single-stage segmental colectomy and anastomosis at a single tertiary care institution in the United States.
78 patients (46%) with incomplete preoperative colonoscopy due to partial obstruction received intraoperative colonoscopy after the anastomosis.
Main Outcome Measures: Detection rates of proximal synchronous lesions, occurrence of post-operative
anastomotic leak and other complications, operative time, and length of hospital stay.
Results: Intraoperative colonoscopy detected synchronous adenomatous polyps in 19 patients (24.4%),
diverticular disease in 15 patients (19%), and colitis/proctitis in 2 patients (2.5%). The overall morbidity in
the intraoperative colonoscopy group was 12.8%, with anastomotic leakage in 1 patient, wound infection in
4 patients, and postoperative ileus in 5 patients. The risk of these complications was not significantly
increased when compared to those patients who received preoperative colonoscopy . (Intraoperative: 29%
vs. Preoperative: 37% p= 0.01) The operation time was 19 minutes longer in the intraoperative group, but
overall length of hospital stay was not significantly different between the two groups (Intraoperative:
6.42.9 days vs. Preoperative: 7.34.6 days).
Conclusions: In patients who received incomplete preoperative colonoscopy due to partial obstruction,
intraoperative colonoscopy after segmental resection and primary anastomosis is both a feasible and safe
strategy for detecting proximal synchronous lesions. This technique does not appear to cause an increase in
anastomotic leak rates, postoperative complications, or length of hospital stay.

Jessica S Crystal, MD1, Steven Tizio, MD2, Min Zheng, MD2, Glenn
Parker2, 1Rutgers-Robert Wood Johnson Medical School, 2Jersey
Shore University Medical Center
Primary leiomyosarcomas of the gastrointestinal (GI) tract are highly aggressive and rare neoplasms. While
a known association exists between leiomyosarcomas and immunosuppression, only a small cohort of cases
have been noted to have been identified in the sigmoid colon, and found simultaneously with a urothelial
carcinoma. To our knowledge, this is the first case of the simultaneous presentation of colon leiomyosarcoma and urothelial carcinoma of the bladder. Here, we report a case of a primary leiomyosarcoma of the
sigmoid colon, in a patient with Crohns Disease and arthritis who is currently being treated with humira and
lialda, who was simultaneously found to have an urothelial carcinoma.
The patient is a 57 year old female who presented for a screening colonoscopy, and was found to have a 3.5
cm friable mass, 40 cm proximal to the anal verge. Initial pathology was consistent with a spindle cell
tumor. The patient then underwent, rectosigmoid colon resection with primary anastamosis, cystoscopy, and
trans-uretheral resection of bladder tumor. Final pathology showed a well, pedunculated, firm rectosigmoid
colon mass with slightly friable/ulcerated surface. The mass was found to be high grade (up to 4050
mitoses per 10 high power fields) and a high Ki67/MIB1 labeling index of 70%. The tumor cells strongly
express smooth muscle actin and were negative for c-KIT, DOG-1, pankeratin, CD34, and S100. The
bladder mass was a pale-pink, tan lesion found to be a high grade papillary non-invasive urothelial carcinoma with no invasion into the muscularis propria and no lymphovascular invasion.
In conclusion, sigmoid colon leiomyosarcoma is a rare neoplasm, but is a diagnosis that should be considered in the setting of immunosuppression. Furthermore, this is the first report of the finding of this
neoplasm in the colon in the setting of an urothelial carcinoma of the bladder.

P095

P097

Two Cases of Laparoscopic-Assisted Simultaneous Resection

of Colorectal Cancer and Synchronous Liver Metastases
in Elderly Patients

Laparoscopic Surgery for Splenic Flexure Colon Cancer

Tomoaki Ito, Tomoyuki Kushida, Mutsumi Sakurada, Hiroshi

Maekawa, Hajime Orita, Koji Senuma, Konomi Mizuguchi, Koichi
Sato, Department of Surgery, Juntendo University Shizuoka Hospital
The liver is the most common site of colorectal metastases. Laparoscopic resection for colorectal cancer and
laparoscopic liver surgery have been widely recognized as safe. In 2015, it has been reported that in multi
experienced centers, laparoscopic simultaneous resection of colorectal primary tumor and liver metastases is
technically feasible and safe. However, the feasibility of simultaneous laparoscopic procedures for colorectal cancer and synchronous colorectal liver metastases in the elderly patients has not been studied
sufficiently.
In this study, two cases of laparoscopic-assisted simultaneous resection of colorectal cancer and synchronous liver metastases in elderly patients are reported. An 83-year-old woman with right hypochondrial
pain was diagnosed with ascending colon cancer and synchronous hepatic metastases in the left lobe of the
liver (segments 2/3) measuring 45mm and the right lobe of the liver (segment 6) measuring 17mm. She had
a history of bronchial asthma. Performance status (PS) was 0. Body mass index (BMI) was 23.6. Laparoscopic-assisted simultaneous resection of colon primary and liver metastases were performed. Afterwords,
laparoscopic ultrasonography was performed. The presence of a hepatic metastasis at the right lobe of the
liver (segment 7) measuring 5mm was also revealed. Hand-assisted radiofrequency ablation (RFA) was
performed because of a tiny tumor and a difficulty of laparoscopic approach. The operative time was totally
470 minutes. The intraoperative blood loss was 340 grams. The patients disease was staged as IV
(pT4apN2apM1a) according to the TNM classification. The postoperative course was uneventful and the
postoperative stay was 23 days.
The other case involved a 78-year-old man with anemia who was diagnosed with ascending colon cancer
and synchronous hepatic metastasis in the right lobe of the liver (segment 6) measuring 10mm. He had
bronchial asthma, hypertension and hyperlipidemia as comorbidities. His PS was 0 and BMI was 26.4.
Laparoscopic-assisted simultaneous resection of colon primary resection and liver metastasis were performed. The total operative time was 471 minutes. The intraoperative blood loss was 240 grams. The
patients disease was staged as IV (pT3pN0pM1a) according to the TNM classification. The postoperative
course was uneventful and the postoperative stay was 17 days. Our results may indicate that laparoscopicassisted simultaneous resection of colorectal cancer and synchronous liver metastases in elderly patients is
feasible and safe. However, further studies with large numbers of patients are needed to establish guidelines
for surgical procedures who undergo laparoscopic-assisted simultaneous resection of colorectal cancer and
synchronous liver metastases.

Kunihiko Nagakari, MD, Masaki Fukunaga, Tetsu Fukunaga,

Seiichiro Yoshikawa, Masakazu Ouchi, Gotaro Katsuno, Yoshinori
Hirasaki, Shintaro Kohama, Juntendo Univ. Urayasu Hosp
Background and Objective: Recently, Hohenberger demonstrated complete mesocolic excision (CME) for
colon cancer surgery. But the laparoscopic treatment of colon cancer located in splenic flexure is not
standardized because of difficulties.
The reason are 1) complex of vascularity, 2) adjacent to vital organs at risk for damage, and 3) extensive
dissection and mobilization.
It is important that we confirm anatomical position to accomplish a precise operation. We can be operated
while securing safe space by approaching it from caudal and cranial side with understanding the structure of
the layer in order to avoid the risk of the damage.
Subjects and Methods: Since 1993, we have performed 2300 laparoscopic colectomies, and at present, the
indication is all colon cancer.
From 1994 to 2015 laparoscopic splenic flexure resection were performed in 38 patients (25 cases of
transverse colon 192 cases, 13 cases of descending colon cancer 105 were necessary dissection of the MCA
and the IMA of the area). These 38 cases were retrospectively investigated.
Surgical technique: Preoperative localization of colon cancer and its blood supply are always important, it
is imperative by using 3D-CT scan.
Step1: The inferior mesenteric pedicle is identified. Medialto-lateral approach is used. Retroperitoneal mobilization of descending colon mesentery up to pancreas. The dissection of the IMA roots is
performed and LCA and IMV are divided.
Step2: Division of lateral attachments of sigmoid and descending colon to splenic flexure.
Step3: The avascular plane between the greater omentum and the transverse colon is divided. The
dissection of the Middle colic artery(MCA) roots is performed and Lt branch of MCA is divided. The
colon at the flexure is retracted caudally, and any remaining restraining attachments are divided.
Step4: Exteriorization and anastomosis through median incision
Results: 2 conversions to open surgery were registered. All cases achieved an adequate number of lymph
nodes harvested (19.6 9.7). Postoperative complication rate according to the ClavienDindo system was
15.8 %, but only 1 complication reported was grade III.
(Wound infection 2, Paralysis 1, Bowel obstruction 1, Leakage 1 stenosis 1)
As to long-term prognosis, 5year cancer-specific survival rate for stage I to IIIa R0 resection were Stage I
100%, Stage II 81.3% and Stage IIIa 87.5% in Japanese Classification of cancer treatment.
Conclusions: This technique for splenic flexure colon cancer is a feasible and reproducible technique and
allow to perform an oncological safe and functionally effective treatment.

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P098

P100

Prediction of Anastomotic Failure Due to Poor Blood Circulation

by the Hypereye Medical Systemtm

Squamous Cell Carcinoma of Unknown Primary Presenting

as a Mass in the Hepatic Flexure

Michiya Kobayashi, MD, PhD, Takayuki Sato, MD, PhD, Hiromichi

Maeda, MD, PhD, Ken Okamoto, MD, PhD, Takeki Sugimoto, MD,
PhD, Ken Dabanaka, MD, PhD, Tsutomu Namikawa, MD, PhD,
Kazuhiro Hanazaki, MD, PhD, Kochi Medical School

Jessica S Crystal, MD1, Nisha Dhir, MD2, 1Rutgers-Robert Wood

Johnson Medical School, 2University Medical Center of Princeton
at Plainsboro

Introduction: We developed a new imaging system the HyperEye Medical SystemTM (HEMS; Mizuho Medical Co, Tokyo, Japan) that
enables simultaneous capture of near-infrared (NIR) indocyanine green (ICG) fluorescence and visible light rays through a unique highly sensitive
charge-coupled device sensor coated with arrays of red-, green-, blue-, and NIR-specific filters. Unlike multiple-sensor systems, HEMSTM enables
real-time color NIR imaging during ICG fluorescence-guided endoscopic surgery without the need for special video data processors to superimpose
NIR images on color images. At SAGES 2013, we described the use of this system to monitor blood supply to the proximal colon during
laparoscopically assisted low anterior resection. We have since treated a patient with anastomotic failure due to poor blood circulation, which was
predicted by HEMSTM during surgery.
Methods and Procedure: A 70-year-old woman who had descending colon cancer underwent a left colectomy. The patient had previously
undergone a sigmoidectomy for sigmoid colon cancer and a right colectomy for ascending colon cancer. We used HEMSTM during the left
colectomy. After mobilization of the left colon and division of the artery laparoscopically, a small laparotomy was made. We injected 5 mL ICG
solution (0.5 mg/mL) intravenously. ICG fluorescence was then detected extracorporeally using HEMSTM.
Results: HEMSTM usually reveals clear arterial blood supply approximately 20 seconds after ICG injection. However, HEMSTM did not show the
arterial phase of the proximal colon in this case, and it showed the capillary phase over 60 seconds after injection. After confirmation of a delayed
blood supply to the proximal and distal colon, a hand-sewn anastomosis was created. The patient experienced severe abdominal pain and a computed
tomography scan revealed anastomotic failure 4 days after the surgery. The patient underwent re-operation, which revealed that some of the colon
was a dark color. This part was resected and re-anastomosed.
Conclusions: Using HEMSTM, we were able to visualize ICG fluorescence at sufficient resolution while the surgical field was under regular light.
Our findings show that delayed blood supply detected by HEMSTM could indicate poor blood supply and result in anastomotic failure.

Primary Squamous cell carcinoma is commonly a disease process of the head, neck, lung, bronchus, cervix, uterus, anus, rectum, and
skin, but at times, the site of primary disease is unknown. While there have been accounts of this disease process arising in the colon,
few reports are published of it being found at the hepatic flexure. Here we present a case of this disease entity which presented in a
79 year old female patient who was found to be anemic with a hemogolobin of 8.3 on routine lab work. Follow up diagnostic tests
included a colonoscopy, during which a friable, fungating mass in the hepatic flexure was found. Pathology from this diagnostic
procedure showed colonic mucosa with benign lymphoid aggregates. Follow up CT scan of the abdomen/pelvis showed a mass
lesion containing air in the right lobe of the liver inseparable from the hepatic flexure of the colon and the gallbladder, without other
abnormalities. The patient then went for operative resection of this mass, but intraoperatively the 12 cm mass was found to be
invading the right lobe of the liver, hepatic flexure, as well as the gallbladder, and could not be safely removed en bloc. The mass
was biopsied then bypassed with an ileotransverse colostomy. Post-operative PET/CT showed intense activity in the large necrotic
mass, a lymph node in the porta hepatis region, and a focus on the left adrenal gland. Final pathology showed well-differentiated
squamous cell carcinoma with extensive necrosis. Tumor markers including Ca 19-9, CEA, and AFP were within normal limits. The
patient had an uncomplicated postoperative course, has been doing well on follow up visits, and has been seen by a medical
oncologist for systemic therapy. In conclusion, it is rare to find squamous cell carcinoma in the colon, particularly in the hepatic
flexure, but when encountered a multi-disciplinary approach for treatment would be beneficial for the patient.

P099
Impact of Routine Fluorescence Angiography in Colorectal
Surgery
Deborah S Keller, MS, MD1, Irlna Tantchou, MD2, Matthew
Schultzel, DO2, Juan R Flores-Gonzalez, MD1, Sergio Ibarra, MD1,
Eric M Haas, MD, FACS, FASCRS3, 1Colorectal Surgical Associates,
2
University of Texas Medical Center at Houston, 3Colorectal Surgical
Associates; Houston Methodist Hospital; University of Texas Medical
School at Houston
Background: Anastomotic leaks represent a major problem in colorectal surgery. In addition to the clinical morbidity and mortality, anastomotic
leaks dramatically increase the length of stay, readmission rates, and total costs of care. Fluorescence Angiography allows real-time visualization of
bowel perfusion during colorectal resection and may lead to a decreased incidence of anastomotic leak. The utility and feasibility of intra-operative
perfusion assessment has been demonstrated in low anterior resection for malignant disease. However, no previous study has assessed the value for
routine use. Our goal was to evaluate the intraoperative and postoperative outcomes using Fluorescence Angiography in benign and malignant
abdominal resections.
Methods: Fluorescence Angiography was utilized in a prospective series of minimally invasive benign and malignant colorectal procedures from
8/1/148/1/15. Right-sided and small bowel resections, and those receiving neoadjuvant chemoradiation were excluded for respective low and high
anastomotic leak rates. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcome measures were the
impact of fluorescence angiography on the planned resection site, the rate of stoma creation, and postoperative complications.
Results: 70 patients were evaluated. The cohort had 41 (58.57%) men, a mean age of 55.77 years (SD14.21), and mean BMI of 27.25 kg/m2 (4.98).
The main diagnosis was diverticulitis (n=23, 32.86%), and the primary procedure performed a low anterior resection (n=29, 41.43%). Procedures
were performed through multiport laparoscopic (n=14), robotic-assisted laparoscopic (n=6), and single-incision laparoscopic approaches (n=50).
Nine patients had changes in resection margin from poor perfusion on fluorescence angiography- all appeared grossly pink and viable. After revision,
all were well perfused on repeat study. Operative times were similar between the revised and unrevised groups (240.49 min [SD86.79] vs. 236.39
[SD87.40], respectively). Three unplanned stomas were created after change in resection margin. Of the 70 patients, only 1 had a postoperative
anastomotic dehiscence/ pelvic abscess. This patient had intraoperative revision of the planned anastomotic site, then readmission for percutaneous
drainage. There was 1 other readmission in the cohort (dehydration), 1 reoperation (bleeding), and no mortalities.
Conclusions: Fluorescence angiography showed value in perfusion assessment for a variety of benign and malignant procedures. Almost 13% of
patient had unexpected poor perfusion, with great potential advantages for preventing an anastomotic leak. Patients with a change in anastomotic site
may require closer postoperative attention. Fluorescence angiography deserves further study for clinical and financial advantages in routine use for
colorectal procedures.

123

P101
Esophageal Stent Migration Requiring Colonoscopic Retrieval
Kaci Sims, MD, Isaac Payne, MD, Leander Grimm Jr, MD,
University of South Alabama
Introduction: Esophageal perforations of benign origin or anastomotic leaks may be treated using temporary covered stents as a
viable conservative treatment strategy. Typically, esophageal stents are removed after six to eight weeks. Well-described complications include tissue ingrowth, stent migration, ruptured stent, obstruction by food, severe pain and discomfort, esophageal
rupture, hemorrhage or death.
Case: We present the case of a 67-year-old female evaluated in the emergency room for complaints of left flank pain. One month
prior to presentation, she underwent placement of a covered esophageal stent for an anastomotic leak after resection of a benign
distal esophageal stricture at another institution. She then failed to follow up after discharge for stent evaluation and possible
removal. CT scan with PO and IV contrast on presentation to us demonstrated migration of the stent into the colon with impaction at
splenic flexure. There was no evidence of a continued esophageal leak. The patient had mild left flank tenderness to palpation but
normal bowel function, absence of laboratory abnormalities and no signs of peritonitis. A colonoscopy with intent for stent retrieval
was performed after bowel preparation. During the colonoscopy, the distal edge of the stent was found impacted against an
inflammatory mass at the splenic flexure. Another inflammatory mass was noted at the proximal end of the stent. The entirety of the
stent was ultimately removed endoscopically with rat-toothed forceps without complication. Cold forceps biopsies and subsequent
pathology confirmed the benign nature of both masses. After the procedure, the patients flank pain resolved, and she was discharged
home tolerating a regular diet.
Discussion: Surgical repair of esophageal perforation or rupture is associated with a high level of morbidity and mortality.
Esophageal stenting offers a minimally invasive alternative for indicated cases. Despite a minimally invasive approach, stent
placements are not without complication. Sources describe migration of esophageal stents into the colon and various management
options including: allowing stents to pass spontaneously in asymptomatic patients, observing and leaving asymptomatic impacted
stents in the sigmoid, manual retrieval for stents in the rectum and colectomy for stents suspected of causing perforation. To our
knowledge, this represents the first reported case of esophageal stent migration, impaction within the colon and successful retrieval
via colonoscopy. We submit that endoscopic retrieval of migrated esophageal stents into the colon can be a safe, effective and
efficient treatment modality for patients who are stable and without signs of peritonitis.

Surg Endosc (2016) 30:S325S500

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P102

P104

Transanal Minimally Invasive Surgery (Tamis) with a Gelpoint

Path for Lower Rectal Tumor

Our Cases by Whom Solitary Rectal Ulcer Syndrom Was

Determined

Shingo Noura1, Masayuki Ohue2, Norikatsu Miyoshi2, Masayoshi

Yasui2, Tae Matsumura1, Masaki Hirota1, Junichi Hasegawa1, 1Osaka
Rosai Hospital, 2Osaka Medical Center for Cancer
and Cardiovascular Diseases

Sebahattin Destek, MD1, Vahit Onur Gul, MD2, 1Tuzla Hospital

General Surgery Dept., Istanbul/Turkey, 2Edremit Military Hospital
General Surgery Dept

Background: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique. However, TEM has not yet achieved widespread use. Recently, transanal minimally
invasive surgery (TAMIS) using single-port surgery devices has been reported.
Methods: We performed TAMIS using a GelPOINT Path in ten patients with lower rectal
tumors. A complete full-thickness excision was performed in all cases. The patient characteristics, operative techniques, and operative outcomes were evaluated.
Results: The mean age of the patients was 61.6 years (range: 4876). The mean operating
time and blood loss were 78.9 min (range: 55110) and 4.4 ml (range 010), respectively.
There were no morbidity or mortality. Resection margin was negative in all cases.
According to the results of the pathological findings, adjuvant chemotherapy was performed
6 patients.
Conclusion: TAMIS using a GelPOINT Path is easy and safe to perform. Although we
only treated a small number of cases, we found that the anal function after surgery was
favourable and that the operation was sufficiently feasible. TAMIS could play a major role
in the resection of large adenomas and early rectal cancers.

P103
Patients Quality of Life After Standard Versus Extra-Levator
Abdominoperineal Excision: A Prospective Case Control Study
D Kamali, A Sharpe, A Musbahi, Y Viswanath, A Reddy, James
Cook University Hospital, Middlesbrough UK
Introduction: Extra-levator abdominoperineal excision (ELAPE) has previously been
demonstrated to reduce levels of circumferential margin involvement and local recurrence
rates, with possible improved patient survival compared to standard abdominoperineal
excision (SAPE). ELAPE is a more radical procedure than SAPE and little is known about
its long-term effects on patients wellbeing. This study set out to determine the long-term
quality of life (QOL) of patients having had ELAPE compared to those having had SAPE.
Methods: Patients who had undergone either SAPE or ELAPE for rectal cancer between
January 2009 and December 2014 at a major surgical unit were recruited into the study.
Patient demographics, peri-operative details and follow-up data were recorded and analysed. QOL was determined using the EORTC QLC-CR30 and QLC-CR29 questionnaires.
Chi-squared, Fisher exact and Mann Whitney tests were used to compare data as appropriate. A P value of \0.05 was considered to be statistically significant.
Results: 45 patients (35 male; mean age 67.4 years; 24 ELAPE cases and 21 SAPE
controls) were studied. One patient who underwent SAPE died within thirty days of surgery. There was no mortality in the ELAPE group. Circumferential resection margin
(CRM) was positive in 2 patients (4.4%), both of whom underwent ELAPE. Both patients
had CRM involvement on pre-operative imaging and had adjuvant treatment. Two patients
(4.4%) had R1 resections, both of whom had undergone ELAPE for a perforated tumour
and CRM involvement and iliac node involvement prior to adjuvant treatment respectively.
One patient who had undergone ELAPE developed local recurrence. While total recurrence
rate was greater in SAPE patients compared to ELAPE patients (24% versus 17%
respectively) the difference was not statistically significant. There was no significant difference in global health score (76.0 versus 65.3) between patients undergoing ELAPE and
those undergoing SAPE, respectively. Impotence was the most frequently reported problem
encountered by both ELAPE (89.7) and SAPE (83.3) patients.
Conclusion: Although a more radical surgery, ELAPE did not demonstrate any significant
impact on QOL compared to SAPE. There was no significant difference in long-term
oncological outcome. Impotence remains a significant problem for all patients and they
should be well informed of this risk prior to surgery.

Aim: Solitary rectal ulcer syndrom (SRUS) was defined in 1829 by Cruveilheir for the first
time, however its real existence was understood in 1969 after the clinical study of Madigan
and Morson. By 35 % of the cases solitary ulcer and by 20 % multiple ulcer were present,
whereas by 45 % no ulcer was present at all. It is met in the society by 0.00001. In general it
is caused by reasons such as colonic intussusception, rectal prolapsus, pelvic floor disorders,
traumatic enema, pelvic radiotherapy etc. It has indications like anal pain, bleeding, mucous
defecation. No indication occurs by 25 % of the patients. The purpose of this study is to
rewiev SRUS cases determined in our clinic.
Material-Method: The data of our six cases followed and treated in our clinic between the
years 20112014 are evaluated retrospectively and discussed in this study.
Results: Two of the patients were male and four of them female and their average age was
48.3 (ages between 3472). Major symptoms were constipation, tenesmus, bloody mucous
defecation. Five patients were found to have anemia. One patient had a history of pelvic
radiotherapy because of prostatic neoplasm. All patients had hemorrhoidal disease. Anal
fistula was determined by one patient, and rectal prolapsus phase I was determined by
another patient. Colonoscopy was applied to all patients and biopsies were taken from them.
Multiple rectal ulcers were observed by one patient and solitary rectal ulcer by the others.
Dietary arrangement, 5-aminosalicylic acid enemata and steroid treatment were given to the
patients against constipation. Patients whose symptoms remitted were followed.
Conclusion: The patients are usually aged under 50. The first preference in the treatment is
dietary arrangement and medical therapy and biofeedback therapy. In surgical treatment,
the rate of failure is more than 50 %. Patients with chronic bleeding, uncontrollable pelvic
pain and complete prolapsus would be candidates for surgical treatment.

P105
Laparoscopic Colorectal Surgery Using Reduced Port Surgery
Device (EZ Access TM)
Kazuki Ueda, MD, Junichiro Kawamura, MD, Koji Daito, MD,
Fumiaki Sugiura, MD, Yasumasa Yoshioka, MD, Yoshinori Yane,
MD, Jin-ichi Hida, MD, Haruhiko Imamoto, MD, Kiyotaka Okuno,
MD, Kindai University Faculty of Medicine
Introduction: Our division started laparoscopic surgery for colorectal cancer (LAC) in 1995.
Over 500 cases of LAC have experienced until the end of 2014. Our current distinctive technique
of LAC is using reduced port surgery devices named EZ AccessTM with LAP PROTECTORTM
mini (Hakko Co. Ltd., Tokyo, Japan) as shown in the picture. This presentation will show our
technique and present the advantages using EZ Access with LAP PROTECTOR mini.

Method: Approximately 3.5-cm umbilical incision is created and placed the EZ Access
with LAP PROTECTOR mini in this incision when starting LAC. Two trocars (12-mm and
5-mm) are placed in the EZ Access. An adequate number of trocar is placed for the
procedure (usually 3 or 4 trocars). Open procedure and the extraction of the specimen are
done through the LAP PROTECTOR mini (just unfixed the EZ Access).
Results: Peri- and post-operative outcomes were equivalent to our method compared to
conventional LAC. Especially, surgical site infection was quite low incidence. There are
several advantages including; (1) Freeing of adhesion around umbilicus is easy to do under
direct vision. (2) Re-pneumoperitoneum is simple just putting on the EZ Access. (3) This
method can respond immediately to incidental hemorrhage or bowel injury.
Conclusion: The EZ AccessTM with LAP PROTECTOR miniTM is useful device to perform LAC.

123

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P106

P108

Laparoscopic Colorectal Surgery in the Cirrhotic Patients: Safe

and Feasible

Surgical Technique and Outcome of Laparoscopic Rectopexy

for Rectal Prolapse

Alberto F Chapa-Lobo, MD1, Raul Ramos-Lopez, MD2, Luis SalgadoCruz, MD1, Marco A Juarez-Parra, MD3, Ulises Caballero-de la Pena,
MD3, Ernesto Miranda-Cervantes, MD3, 1Servicio de Cirugi-a General
Tec Salud. Tecnologico de Monterrey. Campus Monterrey, 2Digestive
Disease Center. University of Texas Health Science Center. San Antonio
Texas, 3Hospital Christus Muguerza Alta Especialidad / UDEM

Junichi Hasegawa, MD, Shingo Noura, MD, Masaki Hirota, MD, Tae
Matsumura, MD, Chikato Koga, MD, Chizu Kameda, MD, Masahiro
Murakami, MD, Ryouhei Kawabata, MD, Masato Yoshikawa, MD,
Junzo Shimizu, Department of Surgery, Osaka Rosai Hospital

Introduction: Major abdominal surgery in cirrhotic patients is associated with high rates of morbidity (3377%) and mortality (1741%). Complications like hemorrhage, sepsis, and metabolic imbalance are common. A 2.59 fold risk for 30-day mortality has been reported in patients undergoing colorectal surgery. Post-operative
mortality is increased along Childs classification.
Advances in laparoscopic surgery have expanded the benefits of MIS to colorectal surgery. Once considered an absolute contraindication, promising outcomes in carefully
selected patients have been reported. We present 3 consecutive cirrhotic patients with associated colorectal disease successfully treated by laparoscopy.
Case Reports: A 75 y.o. male with known alcoholic cirrhosis. He was admitted for fecaluria and pneumaturia for the last 4 weeks. An abdominal CT scan revealed a
cirrhotic liver with dilated portal and mesenteric vessels with splenomegaly and porto-systemic collaterals. Thickening of the sigmoid colon wall and air in the bladder
was also noticed. Classified as Childs A-MELD 11 and underwent a laparoscopic sigmoidectomy with colovesical fistula excision.
An 85 y.o. male with known history alcoholic cirrhosis. He had a 10 m. history of anemic syndrome and weight loss. A tumor was found in the ascending colon on a CTscan. This same study also revealed splenomegaly and dilated splanchnic vessels. Classified as Childs A-MELD 10 and underwent a laparoscopic right hemicolectomy.

Aim: The aim of this study is to examine the clinical and functional outcome of laparoscopic rectopexy in a consecutive series of elderly patients with full-thickness rectal
prolapse.
Method: Sixteen patients (all women; median age 79 years, rage 7292 years, median ASA Grade 2.) underwent laparoscopic rectopexy to treat rectal prolapse between
April 2013 and August 2015. The median prolapse size was 10 [520] cm, and five patients (31.3%) had previous prolapse surgery. Five patients (31.3%) had undergone
pervious pelvic surgery, the most common of which was hysterectomy, performed for 4 patients. Symptomatic and functional data were collected prospectively before
and after surgery. Anorectal physiology was assessed by manometry (maximum resting pressures, MRP, and maximum squeeze pressure, MSP).
Results: Laparoscopic rectopexy with posterior mesh fixation were performed in 14 patients and suture rectopexy in one. Conversion to open technique was needed in one
patient that underwent the suture rectopexy with sigmoidectomy. One patient who could not undergo bowel preparation due to dementia, was complicated with
stercoraceous perforation of the rectum three days after operation and died. Small bowel obstruction was conservatively treated in one patient. Anal incontinence
improved in 5 of 6 patents (83%). Six patients (37.5%) were constipated after surgery. MRP and MSP had improved after surgery.: MRP from a mean of 19.63.1 mmHg
(rage 1525 mmHg) before surgery to 24.013.4 mmHg (1050 mmHg) at 1month and 28.312.4 mmHg (1043 mmHg) 6 months after surgery; MSP from 127.172.4
(60277 mmHg) before surgery to 143.480.1 mmHg (75307 mmHg) at 1month and 173.690.7 mmHg (93359 mmHg) 6 months after surgery. At 10 months, none
experienced persistence or recurrence of rectal prolapse.
Conclusion: Laparoscopic rectopexy as treatment for rectal prolapse resulted in an improvement in anal incontinence and satisfactory control of prolapse.

A 73 y.o. male with history of fecal incontinence due to peripheral neuropathy. He had a 6 m. history of hematoquezia and weight loss. Rectal exam revealed the presence
of a polypoid mass 1.5 cm from the anal verge, biopsy reported adenocarcinoma. Staging CT scan demonstrated a cirrhotic liver. Classified as Childs A-MELD 7. After
neo-adjuvant therapy, he underwent a LAR with taTME and end colostomy.
All patients were operated electively. The preoperative conditioning included: hyposodic regime, fluid restriction, enteral supplements, K vitamin and FFP. Laparoscopic
technique was carried out as routine fashion. Drains placed and removed early to prevent infection. Mean operative time was 160 minutes with minimum blood loss. All
patients developed mild ascites with adequate response to diuretics and albumin. Diet was started once peristalsis was present; the median hospital stay 5 days. No
complications are reported.
Discussion: Management of colorectal disease in cirrhotic patients is not straightforward and data comes from small series. Several reports have demonstrated the
feasibility of laparoscopic surgery in cirrhotic patients with similar results to open procedures. After correct metabolic optimization, MIS seems to be safe in compensated
patients.

P107
Laparoscopic Versus Robotic Left-Sided Colectomy with Low
Pelvic Anastomosis: An Assessment from the ACS-Nsqip
Procedure-Targeted Cohort
Cigdem Benlice, Emre Gorgun, Meagan Costedio, Luca Stocchi,
Maher Abbas, Feza Remzi, Cleveland Clinic, Department
of Colorectal Surgery

P109

Introduction: Robotic surgery is increasingly performed in the management of left-sided colonic and rectal pathologies. In this study, perioperative outcomes of patients
who underwent laparoscopic versus robotic left colectomy with low pelvic anastomosis were compared using the procedure-targeted database.
Methods and Procedures: Data regarding patients who had elective left-sided colectomy were retrieved from the 2013 procedure-targeted American College of
Surgeons National Surgical Quality Improvement Program database. Patients were classified into two groups based on the type of surgical approach: Laparoscopic vs.
Robotic. Demographics, comorbidities, perioperative and 30-day outcomes were compared between the groups.
Results: A total of 3484 patients undergoing laparoscopic and robotic left colectomy were identified. There were 3150(90.4%) patients in laparoscopic and 334(9.6%) in
robotic group. Groups were comparable in terms of preoperative characteristics and comorbidities except for final diagnosis (p=0.004) and dyspnea (4.9vs.2.4%,p=0.04).
Robotic surgery was associated with longer operating times, but also decreased conversion rates and hospital stay when compared to laparoscopic surgery. Overall morbidity
and mortality were comparable between groups (Table 1). After adjusting for confounder, conversion rates became statistically comparable [OR:0.78(CI:0.511.20),p=0.27)]
while robotic surgery remained associated with longer operative times [OR:0.90(CI:0.800.95),p\0.001] but also reduced hospital stay[OR:1.21(CI:1.101.30),p\0.001].
Conclusion: Robotic surgery has similar short-term outcomes when compared to laparoscopic approach with additional benefit of shorter hospital stay in patients
undergoing left-sided colectomy with low pelvic anastomosis.

Table 1

Comparison of perioperative and 30-day outcomes between the laparoscopic and robotic groups
Laparoscopic
(N=3150)

Robotic
(N=334)

Pvalue

\0.001

Operative time*,minutes

21192

253 119

Conversion to open

436(13.8%)

33(9.9%)

0.04

Hospital stay*,days

65.8

5.13.8

\0.001

Superficial SSI

144(4.6%)

Deep SSI

16(0.5%)

2(0.6%)

0.69

Organ-space SSI

126(4.0%)

15(4.5%)

14(4.2%)

0.67

0.75

Bleeding requiring
transfusion

172(5.5%)

15(4.5%)

0.46

Ventilator dependency

28(0.9%)

1(0.3%)

0.52

Ileus

301(9.6%)

28(8.4%)

0.49

Anastomotic leak

115(3.7%)

12(3.6%)

Readmission

287(9.1%)

34(10.2%)

0.52

Reoperation

127(4.0%)

14(4.2%)

0.89

0.96

Morbidity

680(21.6%)

73(21.9%)

0.91

Mortality

17(0.5%)

2(0.6%)

0.70

123

Primary Epiploic Appendagitis- the Great Imitator

Monica Laniado, MD, Ibrahim Matar, MD, Simona Croitero, MD,
Gideon Sroka, MD, MSc, Bnai-Zion Medical Center
Background: Primary epiploic appendigitis (PEA) is considered a rare cause of abdominal pain. With the increasing use of CT scan, the diagnosis of PEA is increasing,
although its true prevalence is not known. Torsion of epiploic appendages resulting in local inflammation can mimic other acute conditions, such as acute appendicitis and
diverticulitis. In contrast to these conditions, PEA is a self-limiting disorder. Our purpose was to describe the clinical features and natural history of this disorder.
Methods: A retrospective search of patients admitted to our department between 2009 and 2014 was made. Diagnosis of PEA was made either by CT or during operation.
Patients demographics, clinical presentation, and treatment were assessed.
Results: 41 patients were identified. In 40 of them (98%) the diagnosis was made by CT scan, which revealed a characteristic lesion. One patient (2%) was operated due
to suspected appendicitis and the diagnosis of PEA was made during operation. Male predominance (63%) was observed and median age was 49 years. The incidence of
PEA in left colon was slightly higher than in the right colon (56% vs. 44%, respectively). 88% of patients had localized abdominal pain, while only in 31% of them it was
accompanied by gastrointestinal symptoms, such as nausea or anorexia. In most patients (61%) rebound tenderness (RT) was absent. Symptoms included fever in 2
patients (5%). Leukocytosis was observed in 24% and mild elevation in CRP was observed in 78%. 9 patients (22%) were initially treated with antibiotics and median
hospitalization duration was 2 days.
Conclusions: PEA is not a negligible disorder. It is characterized by localized pain and usually is not accompanied by fever or GI symptoms. Mild elevation in
inflammatory markers may be observed. The diagnosis is made by abdominal CT scan, which reveals a characteristic para-colic, oval-shaped lesion. A correct diagnosis
enables conservative treatment with symptoms relief in few days.

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P110

P112

Laparoscopic Primary Resection with Anastomosis in Acute

Colonic Diverticulitis

Importance of Protective Ileostomy During Rectal Resection

Martin Galvarini, Francisco Schlottmann, Ezequiel Sadava, Alejandro

Sanchez Ruiz, Manuel Maya, Maximiliano Bun, Nicolas Rotholtz,
Hospital Aleman of Buenos Aires

Lukas Sakra, MD, PhD, Veronica Prochazkova, MD, PhD, Jan Flasar,
MD, Jiri Sller, MD, PhD, Surgical Dept. Pardubice

Introduction: Although Hartmanns procedure has been the standard treatment in patients
with peritonitis due to diverticulitis, there are some studies showing the potential benefit of
the one stage resection with primary anastomoses (PRA). However, this evidence is still
weak. The aim of this study was to evaluate the results of laparoscopic PRA in patients with
acute perforated diverticulitis in a single institution.
Methods and Procedures: From January 2000 to June 2013 all charts of consecutive
patients who underwent a laparoscopic PRA for acute diverticulitis Hinchey III and IV were
revised. These patients were enrolled in Group 1 (G1). Patients underwent to elective
laparoscopic sigmoidectomy due to recurrent diverticulitis were used as a control group
(G2). Demographics, clinical variables and perioperative complications were compared
between both groups.
Results: A total of 266 patients were included, 65 patients (25 %) in G1 and 201 (75 %) in
G2. There were no differences in age, gender, BMI and ASA score between the two groups.
The mean operative time was 193 minutes in G1 and 155 minutes in G2 (p: NS). Intraoperative complication rate was 7% in G1 and 3% in G2 (p: NS). Conversion rate was
higher in G1 (G1 vs. G2: 20% and 4 %, p: 0.01). The length of hospital stay was 4.7 (220)
days in G1 and 3.3 (217) days in G2 (p: NS). Clavien III complications occurred in 11
(16 %) patients in G1 and in 38 (18 %) patients in G2 (p: NS). Anastomotic leak rate was
4.6 % in G1 and 6 % in G2 (p: NS). There was no mortality in the series.
Conclusions: Laparoscopic PRA in patients with acute complicated diverticulitis seems to
be safe and feasible. Prospective investigations with larger series are required to confirm
these findings

Introduction: Anastomotic leakage is one of the most important complications that occur
after surgical low anterior resection for rectal cancer. Protective ileostomy or transversostomy is used during these rectal resection to reduce the consequences of rectal
anastomotic failures. Many studies strictly recommend performing these protective stomies
for the reduction of the anastomotic leakage. On the other hand the closure of protective
stomies is associated with high rate of the morbidity (20%) and the reoperation rate is 8%.
For this reason protective stomies are only used where generally known leakage risk factors
are presented at the Surgical Department Pardubice.
Objective: To determine the efficacy of the protective stoma in the low anterior rectal
resection and if the standard leakage risk factors are the appropriate criteria for providing of
the protective stomies.
Results: In the period from 1.1. 201e to 30.5.2015 we provided 399 procedures for rectal
cancer, of which 197 cases were resection types. We performed during these rectal
resection 34 (17.25%) protective ileostomies or transvestomies in the cases where the
leakage risk factors were presented. In the group of patients with ileostomy we detected 4
(13.3%) patients with complication of having ileostomy, 3 (10%) of them needed the
surgery. Overall 24 anastomotic insufficiencies were noticed (12.18%), 5 of them were in
the group with the protective ileostomy. 6 patients with anastomotic leakages were treated
by axial transversostomy, 1 of these by loop ileostomy, 7 patients underwent rectal
amputation, 2 patients Hartmann resection, 6 patients were treated by manual or endoscopic
lavage and 2 were just observed. However only 5 protective stomies were performed in the
cases where leakages were noticed.
Conclusion: Providing protective stomies in every case of rectal resection is associated
with high rate of complications, predominantly during the closure of these stomies. The use
of the rectal resection leakage risk factors for indication of protective stomies represents
another way to indicate protective stomies. But our experience shows that this approach is
not appropriate in every case. Indication of protective stomies still remains an open
question in the field of low rectal resections.

P111

P113

Comparison Between Open and Laparoscopic Surgery After

Stent Insertion for Obstructive Cancer

Technically Safety and Oncological Validity of Laparoscopic

Surgery in Elderly Patients with Colon Cancer

Toshiyuki Enomoto, MD, Yoshihisa Saida, MD, Emiko Takeshita,

MD, Kazuhiro Takabayashi, MD, Sayaka Nagao, MD, Asako
Takahashi, MD, Ryohei Watanabe, MD, Yasushi Nagaoka, MD, Koji
Asai, MD, Yoichi Nakamura, MD, Manabu Watanabe, MD, Natsuya
Katada, MD, Shinya Kusachi, MD, Department of Surgery, Toho
University Ohashi Medical Center

Ken Kojo, MD, Masanori Naito, MD, PhD, Masahiko Watanabe, MD,
PhD, Takahiro Yamanashi, MD, PhD, Hirohisa Miura, MD, Atsuko
Tsutsui, MD, Naoto Ogura, MD, Keigo Yokoi, MD, Takeo Sato, MD,
PhD, Takatoshi Nakamura, MD, PhD, Kitasato University School
of Medicine, Department of Surgery

Background and Aim: In our department, we have been preoperatively using colonic
stents for obstructive colorectal cancer from 1993, and have performed many stent insertions. In this study, we compared the outcomes of laparoscopic surgery and open surgery
after insertion of a colonic stent for obstructive colorectal cancer.
Methods: From April 2005 to August 2015, 79 patients who underwent surgical treatment
after insertion of a colonic stent for obstructive colorectal cancer at Toho University Ohashi
Medical Center in Japan. The results were evaluated and a comparison between patients
who underwent laparoscopic surgery and open surgery was performed.
Results: We compared amount of bleeding, operative time, hospital stay, and complications
in 45 cases of laparoscopic surgery and 34 cases of open surgery. The amount of blood loss
in the laparoscopic surgery group was significantly less than that in the open surgery group.
However, operative time was significantly shorter in the open surgery group than in the
laparoscopic surgery group. The length of hospital stay was not statistically significantly
different between the groups, but was shorter in the laparoscopic surgery group than in the
open surgery group. There was no statistically significant difference in occurrence of
postoperative surgical complications between the two groups.
Conclusion: In our study, the patients in the laparoscopic resection group had less blood
loss, although no statistically significant difference was found in postoperative morbidity or
mortality.
Laparoscopic resection after metallic stent insertion is a feasible and safe option with high
quality of life for patients with obstructive colorectal cancer.

Introduction: At present, the majority of radical resection of colon cancer is performed

laparoscopically in high-volume hospitals. However short-term and midterm outcomes of
laparoscopic surgery remain unclear in elderly patients (C70 y) with colon cancer. This
study was designed to clarify the technically safety and oncological validity of laparoscopic
resection for elderly patients with colon cancer.
Patients and Methods: The study group was comprised of 269 patients with stage I to III
colon cancer treated by laparoscopic surgery from 2007 through 2012 in our hospital.
Surgical outcomes and postoperative complications were compared between 121 patients
70 years or older (elderly group) and 148 patients 69 years or younger (younger group).
And oncological outcomes were also compared between elderly group and younger group
who were matched for pathological tumor-node-metastasis (TMN) stage.
Results: The mean age of patients was 76.04.5 years old in elderly group and 58.79.0
years old in younger group. There were no significant differences between elderly group
and younger group in operation time (210.8min and 204.1min, respectively), intraoperative
blood loss (59.6g and 43.5g, respectively) and postoperative hospital stay (11.5 days and
9.1days, respectively). Postoperative complications occurred in 24 patients (19.8%) in
elderly group and 23 patients (15.5%) in younger group. The recurrence free survival rate of
elderly group and younger group were similar in stage I (97.3% and 96.2%, respectively),
stage II (94.1% and 95.1%, respectively), and stage III (68.4% and 70.0%, respectively).
Conclusion: Operative outcomes, postoperative complications and midterm oncologic
outcomes were similar in elderly patients and younger patients with colon cancer who
underwent laparoscopic colectomy in our hospital. These results demonstrate that laparoscopic resection of colon cancer is warranted in patients 70 years or older.

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P114

P116

Laparoscopic Radical Right Hemicolectomy Using Caudal -toCranial Approach for Curable Right-Sided Colon Cancer

Short-Term Outcome of Laparoscopic Abdominoperineal

Resection for Lower Rectal Cancer

Liaonan Zou, Guobin Chen, Wenjun Xiong, Yaobin He, Hongming

Li, Ping Tan, Wei Wang, Jin Wan, Guangdong Province Hospital
of Chinese Medicine

Shinobu Ohnuma, MD, PhD, Tomoya Abe, MD, PhD, Hideaki

Karasawa, MD, PhD, Kazuhiro Watanabe, MD, PhD, Hirifumi Imoto,
MD, PhD, Takeshi Aoki, MD, PhD, Katsuyoshi Kudoh, MD, PhD,
Masaharu Ishida, MD, PhD, Naoki Tanaka, MD, PhD, Munenori
Nagao, MD, PhD, Hiroaki Musha, MD, PhD, Fuyuhiko Motoi, MD,
PhD, Takeshi Naitoh, MD, PhD, Michiaki Unno, MD, PhD, Tohoku
University Graduate School of Medicine

Objective: The aim of this study is to compare the safety, feasibility and short-term outcomes of Laparoscopic radical right hemicolectomy using caudal -to-cranial (CtC) approach versus medial-to-lateral (MtL) approach for curable right-sided colon cancer
Methods: Using data from a clinical database in our department, we retrospectively analyzed data of 78 cases undergoing Laparoscopic
radical right hemicolectomy using CtC approach (CtC group) and matched with using medial-to-lateral approach (MtL) group from
August 2010 to January 2015. The matching factors consisted of Sex, Gender, Age, ASA score, BMI, Tumor size, Site of tumor,
Pathological types, TNM stage, Differentiation of adenocarcinoma. Data of intraoperative and postoperative characteristics were
compared between two groups.
Results: The data of clinicopathological characteristics were similar in both groups; there were no significant differences (p[0.05).
All of the operations were successful without conversion to laparotomy. In the intraoperative and postoperative characteristics, there
are no significant differences in average time of ambulation, time to first flatus, hospital stay between two groups. (p [ 0.05),but
there are significantly shorter mean operation time (173.925.39 min vs.193.539.55 min. p \ 0.05) and significantly less mean
total blood loss (92.021.21ml vs. 107.324.67ml. P \ 0.05) in the CtC group than that in the MtL group. The number of lymph
nodes dissected in the CtC group is more than that in the MtL group(32.210.9n vs.228.93n . P \ 0.05) .Although there is no
significant differences in the postoperative complication(abdominal infection, lymph leakage, anastomotic leakage, inflammatory
intestinal obstruction) in the two groups (p [ 0.05),the rate of major blood vessels (SMA,SMV, ICV/ICA, RCV/RCA, Henletrunk,
MCV/MCA) hemorrhage in the CtC group was significantly lower than that in MtL group (14.1% vs. 3.8%. p \ 0.05).
Conclusion: Laparoscopic radical right hemicolectomy using caudal -to-cranial (CtC) approach is technically feasible and safer for
curable right-sided colon cancer based on embryological anatomical logic.It is easy to enter the correct anatomical Toldts space and
easy to dissect the Superior Mesenteric Vein (SMV) and its branches. The procedures are obviously faster and much less bleeding,
more conducive to shorten the learning curve, and the short-term effects are satisfactory.

Aim: To reveal short-term outcome of laparoscopic abdominoperineal resection (lap-APR) for patients with lower rectal cancer.
Materials and Methods: Perioperative factors and clinicopathological features of eleven patients (4 male and 7 female, median age
was 71 years old [1785]) who had lap-APR in Tohoku University Hospital from 2008 to 2015 were compared to those of forty-four
patients with open-APR in the same period.
Results: Patients stage of lap-APR group was I/II/III/IV = 8:1:2:0. On the other hand, that of open-APR group was I/II/III/IV =
8:12:14:10, suggesting that lap-APR tended to be performed for patients with early stage disease. Patients in lap-APR showed
statistically less blood-loss (64 vs 1030 ml, p\0.0001) and significantly shorter operative time than that of open-APR (291 vs 385
min, p=0.0256). There was no significant difference between lap-APR and open-APR in hospital-length of stay (22 vs 33 days, p =
0.19). Post-operative complications were less in lap-APR; Clavien-Dindo grade [or=3 was 9% in lap-APR and 32% in open-APR,
respectively.
Conclusion: Although further large clinical studies are needed, this retrospective study suggests that lap-APR is safe and less
invasive approach for the patients with lower rectal cancer.

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P117

Long-Term Outcomes of Single Incision Laparoscopic Colorectal

Resection (Silc) in Our Consecutive 272 Colorectal Cancer
Patients

The Usefullness of Transanal Rectal Decompression by a Penrose

Drain After Laparoscopic Low Anterior Resection of the Rectum

Goutaro Katsuno, MD, PhD, Masaki Fukunaga, MD, PhD, Tetsu

Fukunaga, MD, PhD, Kunihiko Nagakari, MD, PhD, Kunihiro
Yamasawa, MD, PhD, Seiichirou Yoshikawa, MD, PhD, Masaru
Suda, MD, PhD, Yoshito Iida, MD, PhD, Masakazu Ohuchi, MD,
PhD, Satoshi Kanda, MD, PhD, Yoshinori Hirasaki, MD, PhD,
Mayuko Itou, MD, PhD, Yukinori Yube, MD, Daisuke Azuma, MD,
Shintaro Kohama, MD, Jun Nomoto, MD, Department of Surgery,
Juntendo Urayasu Hospital, Juntendo University
Introduction/Design: We report here the long-term outcomes of the consecutive 272 patients treated with single-incision
laparoscopic colorectal resection (SILC) for colorectal cancer between April 2009 and September 2015.
Technique: SILC was performed using a surgical technique similar to the conventional laparoscopic medial-to-lateral approach.
When it was technically difficult to cut the lower rectum, we often used plus one port or NOSE (Natural Orifice Specimen
Extraction) with prolapsing technique to cut the rectum more confidently.
Results: We reported 272 SILC patients with colon (83.5 %) and rectal cancer (16.5 %). Of them, tumor was located at cecum in 64,
ascending colon in 44, transverse colon in 23, descending colon in 11, sigmoid colon in 85, upper rectum in 39 and lower rectum in 6
patients. TNM stage was 0-I in 146, IIA in 49, IIB in 3, IIC in 2, IIIA in 14, IIIB in 42, IIIC in 10 and IV in 6 patients. T stage was T01 in
120, T2 in 36, T3 in 99, T4 in 17, respectively. There were 135 men (49.6%) and 137 women (50.4%) in this study; the mean age was 65.4
years and the mean BMI was 22.8. We tended to perform SILC for relatively early stage colorectal cancer in right-sided colon, sigmoid
colon or upper rectum. The mean operating time was 152 45 min. The mean bleeding volume was 23 10 ml. One patient (0.37%)
was converted to the multi-port method due to severe adhesion. In 45 rectal cancer cases, NOSE with prolapsing technique was used in
20 rectal cancer patients, and +1 port technique in 18 patients. In total, +1 port technique was used in 28 cases (10.3%). Postoperatively,
there was no mortality and no major postoperative complications such as anastmotic leakage. Postoperative morbidity rates were 3.3 %.
The number of harvested lymph nodes was 256. The mean tumor-free resection margin was 11.7 4.4 cm. The mean follow-up
periods were 4019 months. The 5-year overall survival rates in stage 0III were 95.4%, 100% in Stage I, 100% in Stage II, 90% in
Stage III, and the 5-year disease-free survival rates in stage 0III were 94.6%, 100% in Stage I, 100% in Stage II, 83.3% in Stage III,
respectively.
Conclusion: SILC for colorectal cancer may be a technically and oncologically safe option in strictly selected patients, e.g. low BMI
(\30), relatively low T stage (\T4) and relatively early stage cancer.

123

Iwao Kitazono1, Jun Kadono1, Akira Furoi2, Shunsuke Motoi1,

Tomohisa Futawatari2, Hizuru Kumemura2, Maki Inoue2, Teruhiko
Watanabe3, Masahiko Osako3, Naoki Ishizaki3, Teruo Kumagae4,
Imoto Yutaka1, 1Cardiovascular and Gastroenterological Surgery,
Kagoshima University Graduate School of Medical and Dental
Sciences, 2Department of Surgery, Kirishima Medical Association
Hospital, 3Department of Surgery, Kagoshima Medical Association
Hospital, 4Department of Surgery, Kagoshima Teishin Hospital
Introduction: Anastomotic leakage after laparoscopic low anterior resection of the rectum is a critical complication. Many
procedures have been applied to prevent leakage. We retrospectively evaluate the usefulness of transanal rectal decompression by a
Penrose drain for preventing anastomotic leakage in our department.
Patients and Methods: Seventy-five patients underwent elective laparoscopic low anterior resection for rectal cancer at our
department and affiliated hospitals were included for this study. The rectal anastomosis was performed by end-to-end double-stapled
technique (DST) using Intraluminal anastomosis (ILS). Patients with covering stoma were excluded. The 41 patients were introduced transanal decompression by a 12 mm Penrose drain and 34 patients were not. Patient related factors (age, gender, body mass
index), operative factors (operation time, amount of blood loss, ILS size, transanal decompression) and tumor related factors (site of
tumor; Ra/Rb, depth of tumor invasion; *MP/SS*) were analyzed. Statistical analysis was performed using Fishers exact test,
thev2 test, and Mann-Whitneys U-test for univariate analysis. For multivariate analysis, we used 0.10 as cutoff p value to select the
analyzed factors from the univariate analysis results. A probability of p\0.05 was considered statistically significant.
Results: Anastomotic leakage was observed in 11 of the 75 patients (14.6%). Amount of blood loss (P=0.053), site of tumor; (Rb,
p=0.055), depth of tumor invasion; (SS?, p=0.071), and transanal decompression (P=0.049) on univariate analysis were chosen for
multivariate analysis. Site of tumor (Rb, OR 0.156, p=0.022), depth of tumor invasion (SS*, OR 0.122, p=0.025), and transanal
decompression (OR 0.119, p=0.013) were independent predictors on multivariate analysis.
Conclusion: Transanal rectal decompression by a Penrose drain is a useful technique for preventing anastomotic leakage after
laparoscopic low anterior resection of the rectum for rectal cancer.

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P120

Short Term Outcomes in Laparoscopic Colorectal Surgery

with and Without the Use of Fluorescent Angiography

Application and Standardization of Reduced Port Surgery

in Laparoscopic Rectal Cancer Surgery

Carolyn Moore, MD1, Jacquelyn Turner, MD, FACS2, Clayton

Naddell3, Adatee Okonkwo, MD1, Ed Childs, MD, FACS1, Clarence
Clark, MD, FACS, FASCRS2, 1Morehouse School Of Medicine,
Department of Surgery, 2Morehouse School of Medicine, Department
of Surgery, Section of Colon and Rectal Surgery, 3Morehouse School
of Medicine

Hiroyuki Matsubara, Akiyoshi Kanazawa, Ryo Ohno, Toru Goto,

Takuya Okamoto, Takehito Yamamoto, Yoichiro Uchida, Shugo
Ueda, Akira Mori, Hiroaki Terajima, Kitano Hospital

Background: Laparoscopic colectomy is associated improved short-term outcomes compared to open colectomy. Fluorescent imaging, particularly the use of indocyanine green
imaging in a laparoscopic platform is a relatively recent imaging method showing promise
in improved outcomes in laparoscopic colorectal surgery. Here, we compare 30 day outcomes of laparoscopic colorectal surgeries with (LapFI) and without (Lap) the use of
indocyanine green fluorescent imaging.
Methods: All adult patients who underwent elective laparoscopic (hand assisted, single
incision, or multi-port) colorectal surgery with and without fluorescent angiography were
retrospectively reviewed in a prospectively maintained database from 6/2013 to 6/2015 at a
single institution. Emergent and multi-organ cases were excluded as well as those with
incomplete data. Demographics, intra-operative data, and postoperative data were recorded
and analyzed using STATA 12.
Results: No difference was seen between ages, sex, BMI, comorbidities, or ASA scores
between the two groups. LapFI group (n=30) had significantly longer operative time
compared to Lap group (n=53). There were no conversions to open. No significant difference was seen in the overall complication rate. However, the LapFI group was shown to
have fewer complications at a rate of 6.7% compared to 17% for the Lap alone group
including for anastomotic leak (0% vs 3.8%, respectively). This trend was seen in mortality
and length of stay as well. Readmission rate was higher in the Lap group at 13.2% vs 0% for
the LapFI group.
Conclusion: LapFI is safe and adds more operative time to laparoscopic colorectal surgery
with a trend to a lower complication rate including anastomotic leak.

P119
Laparoscopic Right Hemicolectomy for Goblet Cell
Adenocarcinoid of the Appendix: A Case Report
Lindsay Tse, DO, Joshua Klein, DO, Maurizio Miglietta, DO,
Palisades Medical Center
Goblet cell adenocarcinoid tumors are rare neoplasms that are almost exclusively located in
the appendix. These neoplasms arise from multipotent stem cells in the intestinal crypts,
contain neuroendocrine features, and produce mucin; making these tumors distinct from
adenocarcinomas or carcinoid tumors of the appendix.
Goblet cell adenocarcinoids usually present as a typical acute appendicitis and therefore are
most commonly diagnosed only after surgical removal and pathologic examination. Currently, controversy exists over whether a simple appendectomy is sufficient treatment or if a
subsequent right hemicolectomy is necessary.
This case report describes a patient diagnosed with goblet cell adenocarcinoid of the
appendix, and will discuss some of the current literature and guidelines for treating this
neoplasm. A 48 year old male initially presented to the emergency department with a three
day history of abdominal pain that was localized to the right lower quadrant.
The patient also reported nausea associated with multiple episodes of non-bilious emesis.
Past medical history was significant for diabetes and hypertension, and no previous surgeries were reported. On admission the patient was febrile with a temperature of 101.8, a
WBC of 16.6 and a CT scan that demonstrated a dilated appendix with periappendiceal
inflammatory changes consistent with acute appendicitis.
The patient subsequently underwent an uncomplicated laparoscopic appendectomy and was
discharged on post operative day 1. Pathology revealed goblet cell adenocarcinoid tumor of
the appendix with transmural invasion involving the periappendiceal fat consistent with a
pathologic T3 lesion. Three weeks later the patient returned to the operating room for a
laparoscopic hand assisted right hemicolectomy. Final pathology demonstrated a specimen
with negative margins and 12 negative lymph nodes.
This case illustrates the current controversy over appropriate operative intervention for
goblet cell adenocarinoid tumors. Due to the rarity of these neoplasms, the majority of the
existing literature is composed of small retrospective studies or case reports. Some consensus does exist regarding which patient should undergo right hemicolectomy based on
lesion staging and other pathologic findings. Currently, long term survival benefits have not
been demonstrated with the use of adjuvant chemotherapy or radiation.
Therefore, properly identifying patients who require and would benefit from right hemicolectomy remains a pivotal component in the management and treatment of patients with
goblet cell adenocarcinoid of the appendix.

We already reported simplified lap-LAR technique with straightening rectum using 10mm
forceps and it is very effective approach for standardization and education. Then, we try to
apply our standardized approach to rectal cancer with reduce-port surgery using multiaccess port system. Our standardized approach for Lap-LAR is effective even in reduceport surgery.

P121
Laparoscopic Interval Appendectomy-Problems During NonSurgical Management
Tomoaki Saito, Manabu Watanabe, Koji Asai, Hiroshi Matsukiyo,
Tomotaka Ishi, Asako Takahashi, Takaharu Kiribayashi, Toshiyuki
Enomoto, Yoshihisa Saida, Shinya Kusachi, Toho university, Ohashi
medical center
Background: Interval appendectomy is one of therapeutic strategies for Acute Appendicitis
(AA) . But there are deteriorative and recurrent cases during first non-surgical management.
Aim: To clarify deteriorative and recurrent risk factors for laparoscopic interval appendectomy (LIA).
Patients and Methods: Patients underwent laparoscopic appendectomy for AA from
January 2010 to May 2013. All patients were diagnosed by CT examination in our hospital.
We analyzed deteriorative and recurrent risk factors during non-surgical treatment
retrospectively.
Results: One-hundred-forty-four patients underwent laparoscopic appendectomy (LA).
Eighty-one were man, and 63 were woman. Twelve patients (8.3%) deteriorated and
underwent emergent laparoscopic appendectomy (ELA) during non-surgical management.
Appendicolith rate was significantly higher in the patients who underwent ELA (p\0.01).
One-hundred-thirty-two patients underwent LIA. Twenty-nine patients were recurrent
before LIA. All recurrent patients could undergo non-surgical management again.
Appendicolith rate and abscess formation rate were not significantly different between nonrecurrent group and recurrent group. Time to median recurrent day was 111.5 (range:
11986). Recurrent rate was significantly higher in the patients who tried to undergo 120
days after non-surgical treatment (p\0.01) .
Conclusion: Appendicolith was deteriorative risk factor for first non-surgical management
and optimal timing for LIA was within 4month after non-surgical management.

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P124

Extra Levator Versus Standard Abdominoperineal Excision

for Rectal Cancer: Is There Any Oncological Benefit?

Fast Track Laparoscopic Surgery: A Study in a District Hospital

D Kamali, A Musbahi, A Sharpe, A Reddy, Y Viswanath, James

Cook University Hospital, Middlesbrough UK
Introduction: There are conflicting reports about the superiority of extralevator
abdominoperineal excision (ELAPE) over standard abdominoperineal excision (SAPE),
with only one randomized controlled trial to date showing that ELAPE results in lower
perforation rates and less circumferential resection margin (CRM) compared to SAPE. The
primary aim of this study was to compare oncological and postoperative outcomes of
patients with rectal cancer undergoing ELAPE with those having undergone SAPE.
Method: Data were collected on all ELAPE and SAPE resections for rectal cancer at a
major surgical unit between January 2009 to December 2014 using medical patient records,
radiology, pathology and microbiology information. This included nature of surgery,
pathological circumferential margin positivity (CRM), tumour perforation rates and postoperative complications. Categorical data was statistically analysed using fisher exact tests
where appropriate. A P value of \0.05 was considered to be statistically significant.
Results: A total of 45 patients (35 males) with a mean age of 67.4 years were included in
the study. Six had received open ELAPE while 18 had laparoscopic procedure. There were
8 open SAPE and 13 laparoscopic procedures. Adjuvant treatment was delivered for CRM
positivity on post-operative imaging in 7 SAPE and 13 ELAPE patients. Post-operative
circumferential margin positivity was not significantly different between the two patient
groups, with no CRM involvement in 91.3% in the ELAPE group and 100% in the SAPE
group . There were no significant differences in either post-op collection rates (13% v
4.5%), or post-op bleeding between ELAPE and SAPE, respectively. Ten patients in
ELAPE and 5 in SAPE had perineal wound breakdown. There were no reported cases of
perineal herniation in either surgical group. No patients suffered post-op DVT. Total
recurrence rate was greater in SAPE patients compared to ELAPE patients (24% versus
17% respectively) although this did not reach statistical significance.
Conclusion: There were low rates of CRM positivity in both groups of patients. ELAPE did
not reduce the rate of CRM positivity. Local recurrence rates were lower in patients
undergoing ELAPE however; this did not reach statistical significance. There was no significant difference in oncological or post-operative outcomes between SAPE and ELAPE
resections at our unit. A larger trial with longer follow up is needed.

P123
Single Incision Laparoscopic Surgery for Rectal Cancer: Early
Experience with 41 Cases
Shuodong Wu, Jinyan Han, 2nd General Department
Background: Single incision laparoscopic surgery (SILS) has evolved as an alternative
method to conventional laparoscopic surgery, however, little was known about the suitability of SILS for rectal cancer resection. We performed single incision laparoscopy low
anterior resection (LAR) and abdominoperineal resection (APR) from January 2010. This
pilot study aimed at evaluating the feasibility, safety and oncological outcome of single
incision laparoscopy LAR and APR.
Methods: 41 selected patients underwent either single incision laparoscopic LAR or APR
rectal cancer in the period between January 2010 and February 2015. All the procedures
were performed with the conventional laparoscopic instruments by a single surgeon. The
clinical data, surgical and oncological outcomes were retrospectively reviewed.
Results: Thirty-two patients underwent single incision laparoscopic LAR, while 1 case was
converted to open surgery due to adhesion, the rest were successfully accomplished
(conversion rate 3.1%). Average surgery time was 179.759.3(115300)min and mean
estimated blood loss was 119.081.3(50300)ml. Nine patients underwent single incision
laparoscopic APR, while 3 cases were converted to conventional laparoscopic surgery due
to adhesion or uncontrolled hemorrhage. Average surgery time was
225.653.7(120320)min and mean estimated blood loss was 194.495.0(50400)ml. The
median number of lymph nodes harvested in the resected specimen was 14 (622) and all
operations completely removed the tumor (R0 resection). Complications were seen in 5
patients. At a median follow-up of 35 (666) months, 8 (19.5%) patients developed
metastatic disease. Overall, 3 patients have died.
Conclusion: LAR and ARP for rectal cancer can be safely performed using the SILS
technique in selected patients, with acceptable surgical and oncological outcome. Further
studies are necessary to better evaluate the outcome of SILS for rectal cancer.

123

Angela Maurizi1, Francesco Falsetti2, Giorgio Degano2, Roberto

Campagnacci2, Emanuele Lezoche3, 1Department of General Surgery,
Universita Politecnica delle Marche, 60126 Ancona, Italy, 2General
Surgery, ASUR Regione Marche, Carlo Urbani Hospital, Jesi,
Ancona, 3Department of General Surgery, Surgical Specialties
and Organ Transplantation Paride Stefanini, Azienda Policlinico
Umberto I, Sapienza University of Rome, Italy
Introduction: Fast track program or enhanced recovery after surgery program is a set of
protocols that involves multimodal approaches, including preoperative patient education,
optimizing anesthesia, early postoperative enteral nutrition and early mobilization. The
purpose of this program is to improve clinical outcomes when compared with traditional
care strategies, reducing the postoperative morbidity and shortening the hospital stay.
Although enhanced recovery after surgery protocol in colorectal surgery has been promoted
as a standard, its thorough application is still scarce, due to difficulties in overcoming
cultural and organizational barriers that can hinder its start-up and diffusion. The purpose of
this work is to analyze the possibility to apply the fast track protocol in patients undergoing
colorectal surgery, laparoscopic resections in most cases, in a district hospital.
Methods and Procedures: A prospective, randomized study on 90 patients subjected to colorectal surgery, particularly laparoscopic resections, was conducted in the last year. Patients were
divided in two groups: on one hand the fast track group, undergoing pre-operation physiological
preparation, epidural analgesia, minimally invasive surgery and early mobilization and feeding; on
the other hand the control group that followed the standard treatment.
Data were analyzed using the T-test by Student with significance level p\0.05 and univariate analysis of the relations among the evaluated factors (e.g. post-operative hospital
stay, total hospital stay, overall complications, readmission rates).
Results: The fast track therapeutic protocol was respected in 92% of cases, which showed low
general morbidity. There was no difference in post-operative complications between the fast
track and the control group. The fast track protocol shortens hospital stay and accelerates the
recovery of bowel function with no increase of post-operative complications.
Conclusions: The preliminary results of our survey confirm the applicability and safety of
the Fast Track Surgery. As reported in related literature, compliance with the fast track
procedure was good and morbidity occurrence in general was limited even in this survey
conducted in a district hospital.

P125
Rectopexy with Sigmoidectomy for Rectal Prolapse: A Nationwide
Analysis of Robotic-Assisted vs. Laparoscopic vs. Open Approach
Reza Fazl Alizadeh, MD, Zhobin Moghadamyeganeh, MD, Mark H
Hannah, MD, John Gahagan, MD, Steven D Mills, MD, Joseph C
Carmichael, MD, Alessio Pigazzi, MD, PhD, Michael J Stamos, MD,
University of California, Irvine, Department of Surgery
Introduction: Sigmoidectomy with rectopexy is one of the most common procedures
performed to correct rectal prolapse, and is largely accepted as the most durable procedure.
In recent years, there has been increased utilization of minimally invasive approaches to
perform this operation. The aim of this study was to investigate outcomes of these different
surgical approaches in patients with rectal prolapse.
Methods and Materials: The Nationwide Inpatient Sample (NIS) database were used to
examine the short-term outcomes of patients with rectal prolapse undergoing sigmoidectomy with rectopexy operation from 2009 to 2012. Multivariate regression analysis was
performed to compare open, laparoscopic and robotic approaches.
RESULTS: A total of 1,405 patients with the diagnosis of rectal prolapse underwent
sigmoidectomy with rectopexy between 2009 and 2012. Among them, 809 (57.6%)
underwent open surgery (OS), 480 (34.2%) laparoscopic surgery (LS), and 116 (8.2%)
robotic surgery (RS). The conversion rate for LS was significantly higher compared to RS
(11.7% vs. 0%, P\0.01). Overall mortality rate of patients who underwent OS, LS, and RS
was 1.2%, 0%, and 0% respectively. Following risk adjustment, OS patients were found to
have a significantly higher mortality compared to both minimally invasive approaches
(P\0.01). Overall morbidity rate was also higher in OS patients compared to minimally
invasive approaches (AOR: 1.40, P=0.03), but there was no significant difference in
morbidity between LS and RS (AOR: 0.92, P=0.84). Mean length of hospitalization for OS,
LS, and RS were 7,5, and 4 days respectively. Total hospital charges for OS, LS, and RS
were $48,039, $52,147, and $55,749 respectively. Adjusted mean difference of total charge
between OS and LS, and OS and RS were $4108, CI=(5907627), P\0.05 and $7755,
CI=(17443767), P\0.05, respectively.
Conclusions: Utilization of minimally invasive approaches for rectal prolapse surgery has
increased from 26.6% in 2009 to 45.2% in 2012. Minimally invasive approaches to rectal
prolapse are associated with decreased mortality and morbidity. There is no significant
difference in mortality and morbidity of RS and LS, while the robotic approach has a
significantly lower conversion rate compared to the laparoscopic approach. Minimally
invasive approaches decrease hospitalization duration and postoperative morbidity in the
setting of increased hospital charges. Large prospective studies are needed to validate these
findings.

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P126

P127

Laparoscopic Right Hemicolectomy with Intracorporeal

Anastomosis: Short- and Long-Term Benefits in Comparison
with Extracorporeal Anastomosis

Reduced Port Laparoscopic Appendectomy Versus Conventional

Laparoscopic Appendectomy for Complicated Appendicitis

Ron Shapiro, MD1, Uri Keler, MD1, Stav Sarna-Cahan, MD2, Kamal
Hatib, MD2, David Hazzan2, 1Chaim Sheba Medical Center, TelHashomer, 2Carmel Medical Center
Introduction: Laparoscopic right hemicolectomy with intracorporeal anastomosis is a
procedure of increasing popularity. This study aims to compare short and long term outcomes of intracorporeal and extracorporeal anastomoses
Methods and Procedures: This is a comparative study of two anastomosis techniques for
laparoscopic right hemicolectomy. A total of 191 consecutive patients, operated for neoplasm of
the right colon, were identified. The intracorporeal group included 91 patients and the extracorporeal group 100 patients. Data on patients demographics, disease related characteristics,
operative characteristics, short term outcomes and complications were prospectively recorded.
Data on long term outcomes was retrospectively reviewed. T-Test was used for continues
variables and Chi square was used for analysis of categorical variables.
Results: Patient demographics and disease related characteristics were similar. Mean operative
time was longer in the intracorporeal group (155 vs. 142 minutes; P=0.006). Intracorporeal
anastomosis was associated with less overall postoperative complications (18.7% vs. 35%,
P=0.011) and decreased rate of Surgical Site Infections (4.4% vs. 14%, P=0.023). The need for
post-operative intervention (Clavien-Dindo 3) was higher in the extracorporeal group (7% vs.
0%; P=0.015). There was no statistically significant difference in the incidence of postoperative
leak, ileus and bleeding. Mean length of stay was significantly shorter in the intracorporeal
group (5.92.1 vs.6.93.0; P=0.04). Moreover, more patients with intracorporeal anastomosis
had a length of stay shorter than 4 days (28.6% vs. 14.1%, P=0.015). Extraction incision was
periumbilical in 99% of the patients in the extracorporeal group. In the intracorporeal group
extraction incision was transverse suprapubic (Pfannenstiel) in 85.7%, transvaginal in 9.9% and
periumbilical in 3.3% of the patients. The incidence rate of incisional hernia was lower in the
intracorporeal group (2.2% vs. 17.0%, P=0.001).
Conclusions: Laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short and long term outcomes. The rates of postoperative
complications requiring intervention and incisional hernias are decreased

Shintaro Kohama, MD, Masaki Fukunaga, MD, PhD, Tetsu

Fukunaga, MD, PhD, Kunihiko Nagakari, MD, PhD, Masaru Suda,
MD, PhD, Yoshito Iida, MD, PhD, Kunihiro Yamasawa, MD, PhD,
Seiichiro Yoshikawa, MD, PhD, Masakazu Ouchi, MD, PhD, Goutaro
Katsuno, MD, PhD, Satoshi Kanda, MD, PhD, Mayuko Ito, MD, PhD,
Yoshinori Hirasaki, MD, PhD, Yukinori Yube, MD, PhD, Daisuke
Azuma, MD, PhD, Jun Nomoto, MD, PhD, Juntendo Urayasu
Hospital, Juntendo University
Background: We adopt a single-incision or double-incision laparoscopic appendectomy
(SILA or DILA) in selected patients to improve cosmesis and also reduce the incisional
morbidity. We evaluated SILA and DILA by comparing these 2 techniques to conventional
laparoscopic appendectomy (CLA) for complicated appendicitis including perforated or
gangrenous appendicitis with or without localized or disseminated peritonitis.
Indications: In this study, SILA was basically applied to complicated cases, e.g. gangrenous appendicitis and appendicitis with local peritonitis. However, Plus one-port
technique (DILA) was performed when it was technically difficult to complete SILA
because of some reasons: abdominal severe adhesions, small abscess formation, disseminated inflammations, individual surgeon experience, etc.
Methods: Between January 2009 and May 2015, we retrospectively analyzed 298 patients who
had undergone laparoscopic appendectomy for complicated appendicitis. Of them, 68 had
undergone SILA, 35 had undergone DILA and 195 had undergone CLA. We compared these three
groups for background factors, intraoperative findings, postoperative findings, and hospital stay.
Results: In these three groups, 68 patients with gangrenous appendicitis were found in
SILA, 32 in DILA and 182 in CLA. 3 patients with perforated appendicitis were found in
DILA and 13 in CLA. As for type of intra-abdominal contamination, 67 patients with local
peritonitis were found in SILA, 29 in DILA and 165 in CLA. The number of diffuse
peritonitis was 1 in SILA, 2 in DILA and 9 in CLA. 21 patients with abscess formation were
found in CLA and 4 in DILA. There were no abscess formation cases in the SILA group.
We tended to perform RPS (SILA and DILA) for appendicitis with local peritonitis
(p\0.05). Preoperative WBC counts were similar among three groups though CRP levels
were higher in the CLA than in the SILA and DILA (p\0.05). Operating time, intraoperative blood loss and hospital stay were shorter and smaller in the SILA and DILA than in
the CLA (p\0.05). Oral intake was shorter in the SILA than in the CLA (p\0.05). There
were no significant differences among three groups in postoperative complications,
including wound infection, intra-abdominal abscess, and postoperative ileus. However,
analgesic requirements were higher in the SILA than in the CLA.
Conclusion: This study indicates that RPS (SILA and DILA) are safe and feasible in
selected patients for complicated appendicitis.

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Feasibility of Adaptating the Fundamentals of Laparoscopic

Surgery Trainer Box to Endoscopic Skills Training Tool

Accuracy and Inter-Operator Variability of Small Bowel Length

Measurement at Laparoscopy

Oscar M Crespin, MD1, Allan Okrainec, MD1, Andrea Kwong1, Ilay

Habaz1, Maria C Jimenez, MD1, Jeff Mosko, MD1, Timothy D
Jackson, MD1, Louis W Liu, MD1, Lee L Swamstron, MD2, Eran
Shlomovitz, MD1, 1University of Toronto/University Health Network,
2
Oregon Health Sciences University

Benny Gazer, MD1, Avinoam Nevler, MD1, Barak Bar-Zakai, MD2,

Udi Willentz, DVM3, Ofer Doron3, Mordechai Gutman, MD1, Danny
Rosin, MD1, 1Chaim Sheba Medical Center, 2Kaplan Medical Center,
3
Lahav CRO

Introduction: The SAGES Research Delphi Study prioritized the need to train surgeons
and surgical trainees in flexible endoscopy. The Fundamentals of Laparoscopic Surgery
(FLS) training box is a well-recognized and validated tool, already accessible to surgical
trainees to hone their laparoscopic skills. Seeking a highly available, reusable, low-cost, and
hands-on modality trainer we aimed to adapt the FLS training box and tasks for the
development of endoscopic skills supplemental to Fundamentals of Endoscopic Surgery
(FES).
Methods and Procedures: With ongoing consultation from five experienced surgeons and
gastroenterologists, the setup of the training system and adaptation of FLS tasks were
optimized for endoscopy. Adaptations focussed on utilizing as many of the existing components of the FLS training tool to maintain simplicity while allowing for the testing and
practice of clinically relevant endoscopic skills.
Results: A front attachment panel with different opening options was designed to select the
most ergonomic insertion point for an endoscope into the FLS training box (Figure A). A
shaft provides additional support and limits movement of the endoscope at the point of
insertion, forcing the utilization of the tip of the scope to perform the task (Figure B). A
platform on the inner surface of the panel permits performance of retroflexion tasks (Figure C). The endoscopic tower, originally excluded to minimize complexity of the setup, was
eventually included to more realistically represent endoscopic visualization (Figure D).
Five endoscopic tasks were designed with most utilizing existing components from FLS
(Table 1 and figures E, C, G, H).
Conclusions: An adaptation of the FLS training box has been developed for endoscopic
skills with a focus on maintaining simplicity, reusability, and low-cost. Following validation, this adaptation may act as a training supplementation to the FES program.
Table 1

Introduction: Measurement and assessment of bowel length is a necessary surgical skill needed in various laparoscopic procedures
to achieve good outcomes and avoid complications such as postoperative malabsorption or blind loop syndrome. The current study
is aimed at assessing reliability and inter-rater variability of small bowel length assessment during laparoscopic procedures in an in
vivo porcine model, as the first step towards developing a standardized laparoscopic method for measuring small bowel length.
Methods: Ten senior surgeons, experienced in laparoscopic surgery ([1000 Laparoscopic Procedures) were required to assess and
mark randomly assigned lengths of small bowel (range 25197cm) in both laparoscopic and open approaches using color coded
vessel loops (Fig. 1) in an in- vivo porcine model. The marked distances were later measured by the researchers with surgical tape
measure, and actual distances were compared to the pre-assigned distances. Means of measurements and differences were calculated
for the laparoscopic and open phases. Bland-Altman plots and one sample t-tests were performed using the Statistics Package for
Social Studies (IBM SPSS Statistics Ver.20). This study was approved by the regional animal bioethics committee.
Results: In the laparoscopic phase of the experiment, all the measurements were shorter than the assigned distances (Interquartile
range 58.979.0%). The difference between the assigned distances and the distances assessed by the participants was 33.8
cm28.7cm. This difference was statistically significant (P\0.001, 95%CI 17.849.7, Fig. 2).
In the laparotomy phase, the mean difference and standard deviation were lower (1.5cmSD 15cm) and not statistically significant
(P =0.7) as shown in Fig. 3.
Conclusions: The results of our study suggest that small bowel length assessment during laparoscopic procedures is inaccurate and
non-reliable with a substantial inter-operator variability. Laparoscopic assessments were repeatedly shorter than requested. These
results stress the need for developing a standard laparoscopic technique for measuring small bowel length which is simple,
reproducible, and easy to learn.

Endoscopic Task

Adapted FLS Components

Forward View Peg Transfer (Figure E)

Pegboard, Triangular Rings

Simulation Intentions

Biopsies, General Scope Handling Skills

Retroflexed Peg Transfer (Figure C)

Pegboard, Triangular Rings

Rectum and GEJ Intervention

Puncturing (Figure F)

Precision Cutting

Needle Injection, Tattooing

Snaring (Figure G)

Foam Organ

Polyp Snaring/EMR

Clipping (Figure H)

Suturing Board, Penrose Drains

Muscosal Closure

Fig. 1 .

Fig. 2 .

Fig. 3 .

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The Characterization, Simulation, and Effect of Abdominal Wall

Resistance on Resident Laparoscopic Trainer Performance

Development of a Novel Ex-Vivo Porcine Laparoscopic Heller

Myotomy and Nissen Fundoplication Training Model

Scott W Schimpke, MD, John C Kubasiak, MD, Benjamin R

Veenstra, MD, Jonathan A Myers, MD, Keith W Millikan, MD,
Daniel J Deziel, MD, Jennifer Poirier, PhD, Minh B Luu, Rush
University Medical Center

Hideki Ujiie1, Tatsuya Kato1, Patrycja Bauer1, Hsin-pei Hu1, Priya

Patel1, Hironobu Wada1, Daiyoon Lee1, Kosuke Fujino1, Colin
Schieman2, Andrew Pierre1, Gail Darling1, Kazuhiro Yasufuku1,
1
Division of Thoracic Surgery, Toronto General Hospital, 2Division
of Thoracic Surgery, McMaster University

Introduction: Abdominal wall thickness is associated with increased resistance experienced by surgeons during laparoscopic
surgery. The effect of this increased resistance on surgical performance, both in simulation and in the operating room, is unknown.
The goal of this study was to analyze the relationship between a patients BMI, abdominal wall thickness, and the resultant force
needed to overcome trocar resistance. Furthermore, we hypothesized that adding resistance to a standard FLS trainer, to simulate an
obese abdominal wall, would negatively affect resident performance.
Methods: The BMI, abdominal wall thickness, and force measurements on the 5 mm mid-clavicular right subcostal trocar were prospectively
collected on 21 patients undergoing laparoscopic cholecystectomy from 20142015. For the simulated portion of the study, an FLS trainer box
was used. A resistance model was developed by the addition of a synthetic rubber mold. The performance of general surgery residents (n= 30)
during the standard FLS peg transfer task was tested in both the standard box and the resistance model. Task completion time and number of peg
drops were recorded. PGY1 through PGY5 residents were randomized to start either with or without resistance.
Results: A total of 21 patients were included in the study, with an average BMI of 33.9 (range 13.745.8). Abdominal wall thickness
and force needed to overcome trocar resistance ranged from 1 to 7 cm (mean 4.6 cm, SD 1.6) and 0.5 to 21.5 N (mean 10.5 N, SD
6.2). There were positive associations between BMI, abdominal wall thickness, and the average maximum force needed to overcome
abdominal wall resistance on the trocar. Pearson correlation coefficients ranged from 0.61 to 0.78, and all were statistically
significant (p B .002). Resident performance in the trainer box was negatively affected in the resistance model, which simulated the
forces analogous to a BMI of 29.7 based on linear regression analysis of the aforementioned data. The mean peg transfer times were
92.8 and 199 seconds without and with resistance, respectively (p = 0.03). Task times in both the standard and resistance models
decreased with increased level of resident training.
Conclusions: We demonstrate a positive association between patient BMI and trocar resistance. When applied in a simulation
model, increased resistance negatively affected resident performance at all levels of training. Further studies are needed to
investigate the role of simulated abdominal wall resistance in laparoscopic trainers.

Introduction: Trainees in General & Thoracic Surgery are required to develop competency in a variety of laparoscopic operations.
There is a need to develop a training simulation that can facilitate the trainees transition to performing laparoscopic procedures in a
clinically relevant model. Developing technical skills for laparoscopic heller myotomy and Nissen fundoplication is difficult as there
has been a decrease in the number of procedures performed. These procedures are technically difficult as it requires the ability to
perform the surgery in multiple planes in a three-dimensional environment with two-dimensional visual feedback. This study aims to
develop a cost-effective and anatomically relevant model to be used for training in laparoscopic foregut procedures. We developed
an ex-vivo porcine model to teach surgical trainees the fundamentals of performing a laparoscopic myotomy and fundoplication.
Methods: An ex-vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach,
diaphragm and spleen (Fig. 1). To simulate the normal anatomy, we used an arch system to simulate the normal radial shape and
tension of the diaphragm. A basic laparoscopic box-trainer housed the model. Fifteen surgical trainees and five faculty members
were tested during a training course using this model. They were later asked to complete a course evaluation survey and provide
feedback on the ex-vivo porcine training model.
Results: Fifteen trainees completed the survey. They agreed that the exercise was a valuable use of their limited time, and that
repeating the exercise would be of additional benefit, and that the exercise will improve their ability to perform or assist in an actual
case in the operating room. Significant subjective improvements in mean pre- versus post training in the (1) knowledge level (4.3
vs 7.5, P\ 0.001), (2) comfort assisting (5.1 vs 6.9, P\ 0.05), and (3) comfort performing as the primary surgeon (3.9 vs 6.7, P\
0.001) are depicted. The trainees and faculties unanimously agreed that this model was of adequate fidelity and was a representative
simulation of actual human anatomy. They commented that skills obtained from training with this model are transferable to other
laparoscopic procedures.
Conclusions: We developed an inexpensive, durable, and easily reproducible training model for laparoscopic procedures. This
newly developed ex-vivo porcine model with an arch system simulates human anatomy and increases trainees comfort level in
performing and assisting with myotomy and fundoplication. We believe that this training model will become a significant addition to
laparoscopic training.

Fig. 1 .

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Driven to Innovate: Why Practicing Surgeons Learn New
Procedures and Technologies
Todd A Jaffe, BBA, Steven J Hasday, BS, Meghan C Knol, MS, Jason
C Pradarelli, MS, Justin B Dimick, MD, MPH, University
of Michigan
Introduction: New surgical procedures and technologies are continuously being developed and introduced. For practicing surgeons, the
rationale to seek training in order to learn and implement these new procedures and technologies is personal, variable and largely
unknown. Our aim is to better understand the motives behind surgeons choices to learn something new.
Methods and Procedures: A 22 question survey was created and 77 faculty in the Department of Surgery at a large Midwestern
Academic Health Center were invited to participate in the on-line survey via email. Survey respondents were asked to indicate the
frequency with which they feel internal motivations and external pressures when deciding to learn new procedures or technologies,
then provide on an anchored 5-point Likert-like scale (1 = None; 5 = A Great Role) how great a role specific internal and
external factors played in their decision-making process. Response values were compared using Wilcoxon signed rank tests.
Results: The survey response rate was 71% (55/77). 44% of respondent surgeons have implemented 13 new procedures since
completing their formal training, 35% have implemented 46, and 21% have implemented 7 or more. Nearly all surgeons (98%) indicated
they have felt internal motivation, and 78% felt external pressure to learn a new procedure or technology. Surgeons felt greater internal
motivation compared with external pressures (mean of 3.15 vs. 2.37; p\0.01) when deciding to learn something new. When considering
their internal motivations, surgeons indicated that Improvement for Patients and Enjoyment in Learning Something New provided
the greatest impetus in the decision to learn, with Improvement for Patients regarded as the most important factor (4.54 vs. 3.72,
p\0.01). Surgeons responded that Financial Gains played little role (1.78) in their decision-making.
Surgeons indicated the greatest external pressure was provided by the Medical Community to Remain Current (3.79), Patient
Request (3.26), and Competition with Other Practices (3.09). Pressures from Hospital/Provider Groups (1.88) and Device
Manufacturers (1.77) played a substantially smaller role than the other three (both p\0.01).
Conclusion: Our results indicate that among academic surgeons, internal motivations play a greater role in the decision to learn new
procedures or technologies than do external pressures. The desire to improve outcomes for patients was the most important
motivator, though pressures from the medical community, patient demand, and a desire to remain current play a substantial role as
well.

Simulation Training to Acquire Expertise in Laparoscopic

Pancreatoduodenectomy Reconstruction: Learning Curve
and Transfer of Skills to the Operating Room
Pablo Achurra, MD, Marcel Sanhueza, MD, Rolando Rebolledo, MD,
Juan Francisco Guerra, MD, Fernando Pimentel, Jorge Martinez, MD,
Julian Varas, Nicolas Jarufe, Experimental Surgery and Simulation
Center, Department of Digestive Surgery, Pontificia Universidad
Catolica de Chile
Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is currently a feasible option in selected patients at high volume
centers with available expertise. The long learning curve and associated high morbidity is mainly explained by the technical
difficulty of the reconstruction, specifically the pancreaticojejunum anastomosis. Simulation training has demonstrated to reduce the
learning curve of advanced laparoscopy.
Objective: To present a novel simulation training program for the acquisition of expertise in laparoscopic duct-to-mucosa
pancreaticojejunostomy.
Methods: Experimental study of a training program based on sessions of ascending difficulty to perform a Blumgart laparoscopic
duct-to-mucosa pancreaticojejunostomy in a novel ex-vivo based model. The program consists of 3 stages of ascending difficulty,
wide (8mm), medium (5mm) and thin (less than 2mm) Wirsung duct diameter. Time, global rating scale (GRS), permeability and
leakage of the anastomosis was recorded after each session. To carry on to the next stage the surgeon had to perform a permeable
anastomosis with no leak, in less than 30min and with a GRS[20 points (Max: 25 points).
The trainees were assessed in a thin-duct model before and after the training program to assess the effects of training. After the
simulation the surgeons performed a LPD in the operating room (OR).
Results: Two HPB surgeons with 10 years of experience in open and laparoscopic procedures, but minimal experience in LPD (less
than 2 procedures) underwent the simulation training program to acquire expertise in laparoscopic pancreaticojejunostomy
reconstruction.
In the initial assessment, procedural time was 52 and 55 min, GRS were 14 and 15 respectively and both surgeons had anastomosis
leakage. The number of sessions to complete each stage were 34 in stage one, 44 in stage two and 32 in stage three for each
surgeon respectively (10 sessions in total). In the final assessment, procedural time was 25 and 23 min, and GRS were 24 and 23.
Both surgeons completed the anastomosis without leak and good permeability.
At the moment of submitting this article, only one of the surgeons had performed two LPD in the OR after completing the program
(6mm and 2mm pancreatic duct). The time to perform the anastomosis was 50 and 40 min; GRS 22 and 23 respectively. The patients
had no pancreatic fistula in the postoperative course.
Conclusion: Simulation may reduce the learning curve of complex minimally invasive HPB procedures like LPD duct to mucosa
anastomosis. The skills acquired in the simulated ex-vivo model were transferred to the operating room.

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P136

General Surgery Trainees Seek Robotic Exposure, But Get

Minimal Console Time in Residency

Development of a Novel Video-Based Script Concordance Test

for Laparoscopic Suturing

Walker Julliard, MD1, John R Porterfield, MD2, Aurora D Pryor,

MD3, Rachel R Kelz, MD, MSCE4, Gregory D Kennedy, MD, PhD1,
Mary T Hawn, MD, MPH5, Brent D Matthews, MD6, Nathaniel J
Soper, MD7, Jacob A Greenberg, MD, EdM1, 1University
of Wisconsin, 2University of Alabama at Birmingham, 3Stony Brook
University, 4University of Pennsylvania, 5Stanford University,
6
Carolinas Healthcare System, 7Northwestern University

Ghada Enani, MBBS, MEd, Yusuke Watanabe, MD, PhD, Amani

Munshi, MD, Melina Vassiliou, MD, MEd, FRCSC, FACS, McGill

Introduction: The objective of this survey study was to determine general surgery resident perceptions of robotic surgery.
Utilization of the robotic surgical system has increased dramatically for general surgery procedures over the past several years.
Many of these procedures are being performed at academic medical centers, yet the impact of the adoption of robotic surgery on
resident training has not been assessed.
Methods and Procedures: A 20-item survey regarding perceptions of robotic surgery was distributed online to 261 general surgery
residents enrolled in 7 University-based training programs. Data on demographics, case volume, current training environment,
perceptions of robotic surgery and career goals were collected. Quantitative and qualitative analyses were performed.
RESULTS: There was a 41% response rate (n=108) among surveyed general surgery residents. Respondents were distributed across
all years of clinical training (18% PGY1; 22% PGY2; 20% PGY3; 16% PGY4; 26% PGY5). All 7 training programs utilized the
robot in general surgery. The three most common robotic procedures performed by residents were proctectomy, colectomy, and
cholecystectomy (71%, 43%, and 42% of residents performing these respectively). All respondents reported involvement in robotic
procedures. A minority of residents (33%) reported time spent operating the robotic console and the majority (67%) reported
functioning as the bedside assistant. Of those residents using the console, 53% felt that they had performed more than half of the
case. This was greater than the reported extent of resident involvement in complex laparoscopic cases such as Heller myotomy (35%
of residents completing [50% of the case, p=0.06), but less than the reported extent of resident involvement in basic laparoscopic
cases such as cholecystectomy (70% of residents completing [50% of the case, p=0.053). Most residents (63%) disagreed with the
statement that they would rather perform a robotic case over a laparoscopic case; however, the majority of residents agreed that
it is important for me to receive training in robotic surgery and felt that robotic training needs to be a part of general surgery
residency (71 and 72% respectively).
Conclusions: The utilization of robotic surgery is increasingly penetrating general surgery practice. Residents are being exposed to
robotic surgery at academic medical centers and recognize the importance of this training for their future practice. For the majority
of residents, console time is limited. Implementation of a robotic surgery curriculum could help ensure a meaningful training
experience for residents.

Introduction: Laparoscopic intracorporeal suturing is a challenging skill to acquire. Current surgical training for laparoscopic
intracorporeal suturing is partly based on simulation training, which focuses more on the technical aspects of suturing, and less on
the cognitive and decision-making elements, which tend to vary considerably among experts.
The script concordance test (SCT) is a tool based on cognitive psychology script theory that can be used to measure how an
individual evaluates an ill-defined clinical problem. The goal of this study was to develop a video-based assessment of cognitive and
decision-making skills for laparoscopic suturing and a scoring system based on a modified SCT methodology, and to provide
preliminary validity evidence.
Methods: To define the skill set, a cognitive task analysis (CTA) was performed by having 10 MIS experts review selected videos
on intraoperative suturing scenarios. Using FluidSurveys (http://fluidsurveys.com), an online assessment using videos of a Nissen
Fundoplication and Paraesophageal hernia repair were developed based on the CTA findings. Five-point scales with anchoring
descriptors from -2 to +2 were used (Fig. 1). To calibrate the scoring system, 13 separate MIS expert panelists, completed the
survey. Based on the variability of answers of the panel members, a maximum score of one is given for the response chosen by most
experts, other responses are given partial credit and responses not selected receive zero scores. The SCT was then administered to
participants for test optimization using post hoc elimination of questions with a negative item-total correlation or a correlation of less
than 0.05. Internal consistency of test items was estimated using Cronbachs alpha. Wilcoxon rank test was used to compare scores
between fellows and residents.
Results: Eighteen participants (6 MIS fellows, 3 PGY5, 3 PGY4, and 6 PGY3) completed the 64-item/4 video test. Of a total of 64
questions for 4 videos, 47 questions were selected based on item-total correlation. The internal consistency of test items was 0.91.
The median and interquartile range (IQR) score of the panel was 77.4 [72.381.0]. There was a significant difference between
fellows and senior residents: 67.8 [6281.3] versus 56.6 [31.763.3], p=0.02.
Conclusion: This video-based online SCT for laparoscopic suturing is a novel way to assess clinical reasoning while capturing the
complexity and variability of the clinical environment. This study provides preliminary validity evidence for this tool as a measure
of clinical decision making for laparoscopic suturing.

P135
Development of a Human-Replica Training Box and Organ
Model Based on A Scenario for Simulation of Surgical Procedures
Kazuhiro Endo, MD, Naohiro Sata, MD, PhD, Atsushi Miki, MD,
PhD, Masaru Koizumi, MD, PhD, Hideki Sasanuma, Yasunaru
Sakuma, Alan K Lefor, MD, MPH, PhD, FACS, Jichi Medical
University
Introduction: The aim of this study is to develop a training box that replicates the human intra-abdominal environment with an
organ model based on a surgical scenario.
Methods: Development of the training box: The training box has two parts, a rigid retroperitoneum and a soft anterior abdominal
wall. We replicated the shape of the retroperitoneum using CT scan data. The anterior abdominal wall was designed by measuring
the shape of a human abdominal wall with pneumoperitoneum, and created with soft materials.
Development of the organ model unit: We made a model for training in laparoscopic cholecystectomy. A standard surgical scenario
for laparoscopic cholecystectomy was developed. Each step was delineated, confirming the tasks for each step. We determined the
relevant organs and structures, factors determining the degree of difficulty, surgical instruments used, and potential pitfalls. The
model replicates: gallbladder, cystic duct, common hepatic duct, common bile duct, right hepatic artery, cystic artery, liver,
Rouvieres sulcus, fatty tissue and the peritoneum. These were designed using CT and MRI data and surgical images with 3D
computer assisted design. Polyvinyl chloride was used because the sensation of grasping, dissection and cutting could be replicated
with forceps and an electrocautery.
Results: Surgical training (Fig. 1): Using this training box and organ model, the laparoscopic cholecystectomy procedure was
simulated with real surgical devices. A mono-polar electrocautery was used to cut tissue. Blunt dissection was performed with
forceps. The cystic duct and cystic artery were exposed and identified. A critical view of safety was created. It took approximately
20 min. to complete the simulation training for laparoscopic cholecystectomy.
Development of new surgical devices: For development of new devices, this replica of a human and organ model unit based on a
surgical scenario provided useful evaluation and feedback for further development. This system facilitated communication between
surgeons and engineers.
Conclusion: We developed a human-replica training box and organ model unit based on an actual surgical scenario.

Fig. 1 .

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Fig. 1 An example of the clinical vignette and questions

P137
A Structured, Extended Training Program to Facilitate Adoption
of New Techniques for Practicing Surgeons
Jacob A Greenberg, MD, EdM, Sally Jolles, MA, Sarah Sullivan,
PhD, Sudha P Quamme, MD, MS, Caprice C Greenberg, MD, MPH,
Carla Pugh, MD, PhD, University of Wisconsin
Introduction: The project goal was to critically evaluate the implementation and development process for a newly designed
Continuing Medical Education (CME) level course for laparoscopic Total Extraperitoneal(TEP) inguinal hernia repair. Despite
evidence that the laparoscopic approach for inguinal hernia repair leads to faster recovery, the overwhelming majority of surgeons
continue to utilize an open approach. Moreover, the traditional model of utilizing short CME courses, rarely leads to adoption of
new techniques. Our hypothesis is that our newly developed seven-step program will lead to safe adoption of the TEP approach.
Methods and Procedures: A team of experts in simulation, coaching, and TEP convened to design an educational training program
for TEP. Using an iterative process we developed a curriculum incorporating simulation, intraoperative training, and surgical
coaching. Assessments were created to monitor each stage of the program. Eligible surgeons who performed primarily open inguinal
hernias with a case load of at least 50 inguinal hernia repairs a year and had an interest in adopting TEP into their practice were
recruited through email and postal mailings. Coaches were identified by study team members based on procedural expertise and
completed a formal training program in surgical coaching. Our target enrollment for this pilot project was three practicing surgeons
who were willing to commit to at least eight months of structured training.
Results: The orientation day incorporated didactic and procedural teaching including video-based review and a written assessment.
A simulator was used for a baseline assessment of participants operative skills. After the baseline assessment, trainees were
familiarized with the principles of surgical coaching and were given the opportunity to go over their performance on the simulator
with their assigned coach. The next stage involved GlovesOn training, where the participant scrubbed in with a procedural expert to
observe and perform TEP repairs in the experts operating room. This was followed by the surgical coach precepting several cases in
the participants operating room. The final stage of training involved video-based review of the participants first 10 independent
cases with their surgical coach. Upon program completion, subjects returned for an exit interview and post-test simulation
assessment with their surgical coach.
Conclusions: We were able to successfully implement a CME-level program for training practicing surgeons to adopt the TEP
approach. Necessary considerations for replicating this program at another institution include institutional infrastructure, departmental support and resources, and a team of dedicated personnel for programmatic adaptation and implementation.

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P140

A Questionnaire on the Attitude Towards the Chinese Current

Surgical Training for Residents

Effect of Instituting a Laparoscopic Curriculum on Knowledge

and Retention of Knowledge of Obgyn Residents

Zhifei Wang1, Yi Lu1, Songjia Tang2, 1Hepatobiliary, pancreatic

and minimally invasive surgery, Zhejiang Provincial Peoples
Hospital, 2Zhejiang University, Medical School

Camila Caroline De Amorim Paiva, MD, Nancy Z Tang, MD, Pedram

Bral, MD, Maimonides Medical Center

Abstract Objective: To explore the current concerns the Chinese young residents have during their standardized resident training, taking the residents experience in the digestive disease surgery department of
four large scaled(more than 2500 beds) teaching hospitals as an example.
Methods: The survey was sent to 135 residents from 4 hospitals in Hangzhou.Results 102 surveys were
returned(75.6% response rate). Most of them had a 6 to 12-month long training in digestive disease center.
Results The average study time after work was less than 2 hours per day for 94.11% residents, largely spent
on reading medical related SCI articles and writing papers for academic publication. And only 22.55% of
them spent 1 hour per week exercising on surgical models (mainly suturing and knotting) while the rest had
no time for model training. During work, 1030% time was spent on writing medical record, 520% time
was spent on ward rounding, 3050% time was spent on operation and less than 10% time on study and case
discussion. Though a large amount of time was spent on operation, 60.78% residents admitted they did not
have confidence to perform any surgery independently after surgical training in digestive disease center.
First of all, only 35.29% residents did preoperative study on every operation they involved and only 7.84%
claimed 100 % preparation achieved before operation.Most attendings and fellows did not check residents
preparation before surgery and had trouble instructionally communicating with residents. Lots of residents
were needed at surgery as a result of lack of laborn other than teaching purpose. Retraction, trimming and
suction were 3 mostly performed procedures by residents yet incision, suturing, knotting and dissection were
their mostly desired procedures during surgical training. Too much decumental work occupied quite large
amount of time in the operation room and reduces hands-on exposure opportunities giving the fact that there
is no PA in Chinese hospitals. When doctors finished their surgical training, 34.31% did not take evaluation
tests, 48.04% took theoretical tests and only 17.65% took operational tests, which hindered objective
qualification and skill improvements by positive or negative feedbacks.
Conclusions: The residency education and evaluation system remained to be improved. More than 70%
residents expressed they would lose heart in surgery without operation opportunity. Taking several factors
into consideration, surgical simulation might be ideal compensation for lack of hands-on practice, which
could help residents get more ready and understand better about the surgery.

Numerous obstacles exist for learning the principles and technical skills necessary for minimally invasive
operations. The traditional teaching model is based solely in guiding the residents in the operating room.
However, skill is defined as a well-organized knowledge base in long-term memory, developed with
experience and training for the performance of a targeted task. Hence, we aimed to assess the effect of a
structured laparoscopic curriculum on resident knowledge, as well as on retention of knowledge of the
fundamental principles of laparoscopy.
This is a prospective interventional study, performed at an academic community hospital. Initially, we
administered a pre-intervention test to 20 residents in the OBGYN department. The junior residents (n=10)
were brought through our structured laparoscopic curriculum over the course of the academic year, while the
senior residents continued in the traditional teaching model (n=10). The curriculum consists of classroombased lectures in addition to operating room exposure. The lectures pertained to the fundamental principles
of laparoscopy, we included patient positioning and related nerve injuries, electrosurgery, laparoscopic
equipment, physiological considerations, and laparoscopic complications. After the course of the academic
year, all the residents were administered a post-intervention exam. In sequence, 5 months later, the junior
residents were administered the same exam. Test scores were compared, averages calculated, and t-test
applied.
In the first stage, the average pretest score for junior residents was 35%, and for senior residents was
42.14%. On the other hand, the average posttest score for junior residents was 75.71%, and for senior
residents was 48.70%. This means, in absolute numbers, that the junior residents group improved 40.71%,
while the senior residents improved 6.42%, which is a statistically significant difference (t-value=4.5;
p\0.01). In the second phase, 5 months after the course of the academic year, the average score for junior
residents was 66.42%. Compared to their initial posttest score (75.71%), there was no statistically significant
difference (t-value=1.5, p=0.14).
Introducing a laparoscopic curriculum to a residency program has a significant impact on improving resident
knowledge of the fundamental principles of laparoscopy, as well as in retaining the acquired knowledge.
Future studies are underway to evaluate the effect of a structured didactic curriculum on resident operating
room performance.

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P141

A Review of a Laparoscopic & Endoscopic Training Program

in Central Haiti

Thinking Outside the [Trainer] Box: A Competition Curriculum

to Develop Laparoscopic Proficiency and Problem-Solving
in Surgical Trainees

Luther Ward, MD1, Michelson Padovany, MD2, Alexis N Bowder3,

Andre Patrick Jeudy, MD2, Frank Junior Turenne, MD2, Thomas
McIntyre, MD4, John G Meara, MD1, Jean Louis Mac Lee, MD2,
1
Boston Childrens Hospital, 2Zamni Lasante-Partners in Health,
3
University of Nebraska Medical Center, 4SUNY Downstate Medical
Center
Introduction: After thirty years of implementation, laparoscopic procedures have become the gold standard
of treatment for a number of procedures in advancing countries. This is in part due to the consistently
documented benefits of minimally invasive surgery. Despite this there still remains considerable controversy
and resistance to implementing laparoscopy in resource poor settings amongst surgeons from high-income
countries. For the last two years the Hopital Universitaire de Mirebalais (HUM) in Haiti has provided
surgical care to over 4,000 patients. Recently a laparoscopic and endoscopic training program has been
initiated for Haitian surgeons and surgical residents.
Methods & Procedures: This project is a descriptive analysis of our experience implementing endoscopy &
minimally invasive surgery at HUM. The endoscopy program was initiated in January of 2014 and focused
on endoscopy and colonoscopy. The laparoscopic program was introduced in October 2014 by the
department of surgery at HUM and consisted of basic laparoscopic procedures such as cholecystectomy,
appendectomy and diagnostic laparoscopy. Outcomes, complications, rates of conversion to open procedures, and procedures needed for laparoscopic competency were recorded.
Results: After five months of endocscopy/colonoscopy training and ten months of laparoscopic training with
an American general surgeon Haitian surgeons were able to perform endoscopy, colonoscopy, and
laparoscopic cholecystectomies safely. In total, 240 endoscopic procedures and 30 laparoscopic cases
performed at our institution. There were no perioperative deaths and 4 laparoscopic appendectomies were
converted to open procedures due to dense adhesions.
Conclusion: We believe this study demonstrates that endoscopy and laparoscopy can be taught and used
safely in low-income settings. In addition, training surgeons can be done efficiently and result in satisfactory
perioperative outcomes. Documentation of this is incredibly important so that minimally invasive surgery
can been seen as an adjunct and necessary component to developing surgical systems in low-income
countries.

N Lafayette, MD, D Ricaurte, MD, J Dussel, MD, J Gauthier, MD, S

Kurtzman, MD, L Melman, MD, Waterbury Hospital
Intro: Surgical trainees are faced with pressure to learn more in less time. It takes about 10 hours (600
minutes) of dedicated practice time for a novice to reach basic laparoscopic proficiency. This requires
dedicated practice outside the OR; however, this is often difficult for residents to achieve in their first year of
training. In addition to manual skills, residents must also learn effective management skills. This aspect of
training is difficult to simulate. The objectives of this study were: 1) to develop a competition curriculum
and see if our interns would reach the 600-minute mark by its end, 2) to observe the voluntary usage (in
minutes/week) of the skills lab before, during, and after curriculum implementation, and 3) to see if adding a
teamwork dimension halfway through the competition would increase skills lab usage.
Methods: Twelve residents (PGY levels 15) were asked to practice FLS tasks from the validated curriculum. Participation was not required. All trainees had unrestricted access to trainer boxes and practice
materials. All four interns had little or no prior experience with FLS. The curriculum was run between
FebruaryMay 2015. In February & March, residents practiced tasks on their own. During April & May, any
PGY level first-assist was allowed and competitors could develop strategies for time reduction. Top Gun
was awarded for lowest time based on time and accuracy. Wingman was awarded for highest score based
on strategy development. The time each resident spent in practice was tracked using a logbook and the
Hours Keeper app. Minutes for each intern were then totaled, and the monthly sum of resident-minutes for
all PGY levels was quantitated. Students t-test was used to compare means, and significance was set at
p\0.05.
Results: Three of the four interns achieved greater than or equal to 600 minutes of practice time by the end
of the competition (range 5782975 min). In total, ten of twelve residents eagerly participated in the
curriculum. The usage of the skills lab increased significantly compared to baseline (Fig. 1). Although
practice time was not significantly more after addition of a team strategy element, it was successful in
maintaining usage hours higher than baseline.
Conclusions: A competition curriculum motivates surgical trainees to practice and can help them achieve
proficiency during their first year of training. Through this model, any PGY-level trainee can practice
manual as well as team management skills in a simulated environment.

Fig. 1 .

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P142

P144

Laparoscopic Skill Assessment of Practicing Surgeons Prior

to Enrollment in a Surgical Trial of a New Laparoscopic
Procedure

A Comparison of Attending Versus Resident Opinions Regarding

Morbidity and Mortality Conference at a General Surgery
Residency Program

Benjamin Zendejas, MD, MSc1, James W Jakub, MD1, Travis E

Grotz, MD1, Alicia M Terando, MD2, Amod Sarnaik, MD3, Charlotte
E Ariyan, MD4, Mark B Faries, MD5, Sabino Zani Jr., MD6, Heather
B Neuman, MD, MS7, Nabil Wasif, MD8, Jeffrey M Farma, MD9,
Bruce J Averbook, MD10, Karl Y Bilimoria, MD, MS11, Douglas
Tyler, MD12, Mary S Brady, MD4, Jeffrey D Wayne, MD11, Todd
A Kellogg, MD1, David R Farley, MD1, 1Mayo Clinic - Rochester,
2
Ohio State University, 3H. Lee Moffitt Cancer Center, 4Memorial
Sloan Kettering Cancer Center, 5John Wayne Cancer Institute, 6Duke
University, 7University of Wisconsin - Madison, 8Mayo Clinic Arizona, 9Fox Chase Cancer Center, 10Metrohealth Medical Center,
Cleveland, 11Northwestern University, 12University of Texas,
Galveston

Courtney Cripps, MD, Parswa Ansari, MD, Gary Giangola, MD,

Robert Andrews, MD, Northshore LIJ Lenox Hill Hospital

Introduction: Outcomes of surgical trials hinge on surgeon selection and their underlying expertise. How to best document
surgeons expertise prior to enrollment in a surgical trial is not known. We investigated whether surgeons performance measured by
the fundamentals of laparoscopic surgery (FLS) assessment program could predict their performance in a surgical trial.
Methods: As part of a prospective multi-institutional study of minimally invasive inguinal lymph node dissection (MILND) for
melanoma, surgical oncologists experienced in open inguinal dissection, but no prior MILND experience, participated in a one-day
MILND training course (didactics, video review, and cadaver training). All participants underwent pre-course assessments on the 5
FLS tasks. Subsequently, each surgeon submitted videos of each MILND case performed in the surgical trial. Videos were scored
with the global operative assessment of laparoscopic skills (GOALS) tool by two independent raters. Associations between baseline
FLS scores and participants trial performance metrics were assessed.
Results: Twelve surgeons enrolled patients; their median total baseline FLS score was 332 (range 275380, max possible 500,
passing [270). Participants enrolled 87 patients in the study (median 6 per surgeon, range 124), of which 72 (83%) videos were
adequate for scoring. Baseline median MILND operative performance (GOALS) score was 17.1 (range 9.621.2, max possible score
30). Inter-rater reliability was excellent (ICC=0.85). Greater baseline FLS scores correlated with improved baseline GOALS scores
(r=0.34, p=0.05) and with shorter operative times (r=-0.24, p=0.02). No associations were found with the degree of patient
recruitment (r=0.02, p=0.7), lymph node count (r=0.01, p=0.07), conversion rate (r=-0.06, p=0.38) or major complications(r=-0.14, p=0.6).
Conclusion: FLS skill assessment of surgeons prior to their enrollment in a surgical trial is feasible. Although better FLS scores
predicted improved operative performance and operative time, other outcome measures showed no difference by FLS performance.
Our findings have implications for the recruitment and documentation of laparoscopic expertise of surgeons and potential success of
surgical clinical trials.

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P145

Examining the Efficacy of a Novel Mental Skills Curriculum

Implemented with Surgical Novices

Offering Robotic Surgical Education During General Surgery

Residency

Nicholas E Anton, MS1, Lisa D Howley, PhD1, Manuel E Pimentel,

BS1, Cameron K Davis, BA1, Charles Brown, PhD2, Dimitrios
Stefanidis, MD, PhD3, 1Carolinas Simulation Center, Carolinas
HealthCare System, Charlotte, NC, 2Head in the Game Inc, Charlotte,
NC, 3Department of Surgery, Carolinas HealthCare System,
Charlotte, NC
Introduction: Stress has been shown to negatively impact surgical performance. Surgical novices are more susceptible than experts
to experience intraoperative stress. Mental skills are psychological strategies that enhance performance and reduce stress, and have
been routinely implemented in other domains (e.g., military, elite athletics, etc.) to optimize performance. The purpose of this study
was to develop a novel mental skills curriculum (MSC) to reduce surgical novices stress and increase their use of mental skills.
Methods and Procedures: After the initial development and refinement process, the MSC was implemented with a convenience
sample of surgical novices during their 8-week fundamentals of laparoscopic surgery (FLS) training. Participants state (i.e.,
emotional state at a moment in time) and trait (i.e., proneness to stress) anxiety was measured at baseline and post-test with the
State-Trait Anxiety Inventory (STAI-F), and their use of mental skills during performance was captured with a modified version of
the previously validated Test of Performance Strategies (mTOPS-3). A paired T-test was used to analyze the results.
Results: Nine novices (age 23 7 years, 55% women) completed the MSC. Their FLS performance was significantly improved after
training (Objective suturing score was 13.33 at baseline, 424.88 at post-test; p\.001). There was a significant reduction in state and
trait anxiety and increase in the use of mental skills by participants at post-test compared with baseline (see Table 1).
Conclusion: The novel MSC developed and implemented in this study was effective at reducing surgical novices anxiety and
increasing their use of mental skills. This curriculum may be valuable to help surgical trainees reduce intraoperative stress and
increase their use of performance enhancing strategies, which could ultimately increase patient safety in the operating room.
Additional research on the effectiveness of this curriculum is currently underway at our institution.

Table 1

.
Baseline

Post-test

p-value

STAI-State Anxiety*

41.11

32.11

p\.05

STAI-Trait Anxiety*

45.78

40.56

p\.001

Positive Self-Talk+

3.19

4.19

p\.01

Emotional Control+

2.83

3.47

p\.01

Mental Imagery+

3.92

4.44

p\.01

Activation+

3.31

4.11

p\.005

Relaxation+

3.22

4.36

p\.01

Attention Control+

2.94

3.67

p\.05

*- Lower scores indicate lower stress;

+ - Higher scores indicate more use of mental skills

123

Objective: To compare attending surgeon and resident perceptions of the weekly morbidity and mortality conference at an
Accreditation Council for Graduate Medical Education (ACGME) accredited general surgery residency program.
Background: A hallmark of surgical education, morbidity and mortality conference was introduced following the publication of the
Flexner report in 1910 and the creation of the American College of Surgeons in 1912. The conference facilitates discussion between
faculty, residents, and ancillary staff. Discussion allows for the assessment of errors made and resultant complications while
providing an opportunity for the suggestion of solutions. These conferences are a vital component of the peer review process
exercised by most medical centers, and are a strict residency requirement mandated by the ACGME.
Methods: A confidential survey was presented at the weekly conference between October 29th and December 17th 2014. The
questionnaire was attached in a randomized fashion to the weekly case summary. The survey contained 13 items, 10 of which were
directly related to attitudes towards morbidity and mortality conference, and a 5-point Likert scale was employed to weigh the
responses.
Results: A total of 40 respondents completed the survey (21 attendings, 13 residents and 6 others including students, physician
assistants, pharmacists or nurses). A result was considered statistically significant at the p\0.05 level. All analyses were performed
using SAS version 9.4 (SAS Institute, Cary, NC) except stripchart graphs, done using R version 3.2.0 (R Foundation for Statistical
Computing, Vienna, Austria). There was a significant association between number of conferences attended and rank (p=0.0005). The
level of agreement with the proposed statements was significantly higher for attendings than for residents when identifying the
conference as a means to reflect and improve upon performance, to employ leadership skills that improve upon professional
development, and in the confirmation that criticism provided by attendings is constructive (p=0.049, p=0.01, p=0.007).
Conclusions: Morbidity and mortality conference has been a mainstay of surgical education and remains a necessary element of
training. With the changing climate of surgical residencies, it is suggested that the morbidity and mortality conference undergo
modifications to ensure its present and future utility in producing competent and confident surgeons. Despite agreement between
attending and resident surgeons in many benefits of morbidity and mortality conference, statistically significant differences exist in
vital opinions and deserve reconciliation in order to create fluidity amongst the present and future leaders of this field.

Ankit Patel, MD1, Jamil Stetler, MD1, Jay Singh, MD2, Jahnavi
Srinivasan, MD1, Keith Delman, MD1, John Sweeney, MD1, S. Scott
Davis, MD1, Edward Lin, DO1, 1EMORY UNIVERSITY, 2Piedmont
Colorectal Associates
Background: There has been a significant growth in robotic surgery in the field of general surgery in the past few years. Many
residency programs, especially in urology and gynecology, have attempted to incorporate training into their curriculum but struggled
to standardize the process, forcing many residents to seek additional training or fellowships. Several surgical subspecialties, such as
cardiothoracic, pediatrics, colorectal, oncology, and minimally invasive, enroll their fellows into training courses. In general surgery
residency programs, formal training exists for laparoscopy and robotics is a natural extension of this skill set. We illustrate a training
model for residents during their general surgery residency to achieve proficiency that would allow them to perform robotic surgery
without any further training.
Methods: We began by examining the training provided by Intuitive Surgical to prospective surgeons interested in robotic surgery.
In 2013, they developed an equivalency certificate that could be obtained by fellows during their training as long as they met the
minimal criteria. We expanded on these minimal guidelines and incorporated prior published data on simulator training and skill sets
needed to perform robotic surgery safely to develop a curriculum that would measure not only performance during a case, but also
develop knowledge about troubleshooting and safety for the patient. The curriculum consists of the following: 1) reviewing online
modules designed for the surgeon as well as the assistant, 2) completing 14 simulator exercises that are critical for energy
application, camera manipulation, economy in range of motion, and needle handling, 3) hands-on course designed by the surgical
staff, 4) minimum of 10 cases as bedside assistant, and 5) minimum of 20 cases as console surgeon. The last 5 cases were discussed
pre/postoperatively, recorded, and reviewed by current robotic general surgery faculty.
Results: Since 2013, 6 minimally invasive fellows have completed the requirements and graduated with the equivalency certificate.
Of the 6 MIS fellows, 2 are in academic practices and currently train residents in robotics. 3 of the other 4 fellows are successful
robotic leaders in their private practice groups. In addition, 3 residents also completed the requirements and did not require any
formal training during their fellowships. All of the participants showed improvement in operative times and overall performance
during their 5 cases.
Conclusion: Formalized training needs to exist for robotic surgery and can safely be incorporated into residency training, especially
for those interested in robotic surgery.

Surg Endosc (2016) 30:S325S500

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P148

Feasibility of Remote Administration of the Fundamentals

of Laparoscopic Surgery (FLS) Skills Test Using Google Glass

Endoscopic Painting as Pelvic Box Training Exercise

Anton Nikouline, BS1, M. Carolina Jimenez, MD2, Allan Okrainec,

MD, MHPE3, 1University of Toronto, 2Temerty/Chang
Telesimulation Centre, Toronto, 3Division of General Surgery,
University Health Network
Introduction: The Fundamentals of Laparoscopic Surgery (FLS) program is a simulation-based training course designed to teach and assess the
basic cognitive and technical skills necessary for laparoscopic surgery. The skills component consists of five tasks scored for both efficiency and
precision. Preliminary work has demonstrated the feasibility of using Skype as a telesimulation modality in reliably scoring the exam for remote
centers. Google Glass (Mountain View, California) is a wearable computer containing a heads-up display and front-facing camera allowing point-ofview video transmission. The objective of this study was to evaluate the feasibility of Google Glass in scoring the technical skills component of the
FLS exam.
Methods and Procedures: Twenty-eight participants consisting of 1 OR nurse, 9 medical students, 13 General Surgery (GS) residents, 2 GS fellows
and 3 general surgeons were recruited for the study. Participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using
Google Glass and Skype setups. Google Glass was equipped with HIPAA-compliant Eyesight (Pristine Inc. Austin, TX) software for video
transmission. Participants were alternated between setups and evaluated by on-site and remote proctors. Times and errors were recorded by both
proctors. Interrater reliability of their FLS scores were compared using Intraclass Correlation Coefficients (ICCs). Google Glass experience was
evaluated based on participant survey responses on a 5 point Likert scale.
Results: Google Glass trials demonstrated statistically significant correlation between proctors with ICCs of 0.985 (95% Confidence Interval [CI],
0.9690.993) and 0.997 (95% CI 0.9930.998), respectively for peg and suture tasks. Skype trials for both tasks demonstrated ICCs of 1.0 (95% CI
1.01.0). Average Likert scale responses from users found Google Glass to be distracting (2.71), obstructive of the view (2.79) and a limitation to
task execution (2.75). Although overall there was no statistical difference in scores between Google Glass and Skype setups for either the peg
(t=1.446, p=0.154) or suture tasks (t= -0.710, p=0.480), only 1/28 participants found the use of Google Glass superior to Skype.
Conclusions: Our findings suggest that although Google Glass is feasible in remote assessment of FLS with strong interrater reliability (ICC[0.95),
Skype software is the preferred modality by participants. Further research is needed to better define the role of Google Glass and other wearable
computers in simulation training and assessment.

Michael Dennis I dela Paz, MD, AMOSUP Seamens Hospital,

Intramuros, Manila
It is proven that the use of simulators in laparoscopy such as that of laparoscopic trainer box exercise have significant advantage to skills
development in supplement to standard preceptorship program. Various tasks such as bead transfer, grape peeling, shape cutting and rope running
develops hand eye coordination, depth perception, spatial coordination instrumental tactile feedback, tissue handling skills and improvement of skills
of non-dominant hand. The strength of these exercises is that it lessen the steep learning curve in laparoscopic surgery. The weakness of these
exercises is that the sequence of being repetitive and the absences of aim of achievement makes it boring that most of the trainee surgeon in a basic
surgical workshop would just spend just a few minutes to the exercise. In an international study, they found out that at least 30-minutes a day or at
least 3 hours a week of laparoscopic box exercise is needed to significantly acquire the needed skills in laparoscopic surgery.
It is the above mentioned weakness factors of standard laparoscopic box trainer exercises that modification of the exercise was done in a creative and
enthusiastic way through endoscopic painting during the laparoscopic preceptorship training of the author. The purpose of this paper is to introduce
an innovative, creative, and enthusiastic way of skill exercise in Laparoscopic Box Trainer through Endoscopic Painting for the improvement of
learning curve in basic laparoscopic skills of the trainee surgeon. Innovation and recycling of an old disposable laparoscopic dissector was done
replacing its tip with the tip of the paint brush. A makeshift laparoscopic box trainer with a horizontal metal bar was used for the attachment of a
miniature canvas. Using the tools of children in their art class such as set of acrylic or oil paint and the mixing/washing container, the author was able
to create his first miniature masterpiece entitled the Biliary Tree for around one hour, a disastrous painting as of that of a Pre-school student but
the experience proved that the exercise procedure is feasible and rewarding. Further modification of the instrument specifically creating the long
shaft paintbrush which mimics the laparoscopic hook dissector made the painting exercise as if the trainee is dissecting the peritoneum of the
gallbladder from the liver bed or cauterizing the bleeder in the liver bed using the hook. With time I was able to develop author trainee developed his
endoscopic skills as well as enjoyed painting.

P147
Who Took Away the Due Surgery from the Chinese Residents
and How to Make It Up
Zhifei Wang1, Yue Gao2, Dahong Zhang3, Defei Hong1, Hong
Wang4, Yan Li5, Dongsheng Huang1, 1Department of Hepatobiliary,
pancreatic and minimally invasive surgery, 2Biomedical Engineering,
Cleveland Clinic Foundation,9500 Euclid Ave, Cleveland, OH
44195., 3Department of Urology, Zhejiang Provincial Peoples
Hospital, 4Department of Anesthesiology, .Wayne State University/
Detroit Medical Center.McLaren Flint Hospital. Detroit, MI, USA,
5
Department of Neurosurgery, University of Rochester Medical
Center, 601 Elmwood Ave, Rochester, NY 14642
Abstract Background: The Chinese surgical training is always confusing to most of the surgeons outside of China. In fact, such training, being not
regulated and efficient, is even more complained by the residents. The worse is that such problem is not fully paid attention and current system and
situation are limited in the solution.
Objective: To explore the underline reasons for the Chinese residents current status of being deprived of surgical training, esp, for hand on training,
at many teaching hospitals during their Chinese standardized resident training. And to propose a possible solution for this problem given such
background.
Methods: The reasons were analyzed from different angles: the residents side, the attendings side, the hospitals side and the patients side. Also
the current conflicts and controversy in Chinese medical education system were analyzed. The advantages of the surgical training system of America
were discussed and compared. A simulation based training approach was suggested given the fact that many underlining causes are not supposed to
be solved within short time.
Results: The current Chinese surgical training system is far from being sufficient to provide the resident enough exposure for surgical training. The
simulation system, though still a lot the be accomplished, is an alternative choice.
Conclusions: Surgical residents should be paid more attention for their hand on training, the simulation system may better meet the basic
requirements in a safe and effective way.

P149
Advanced Laparoscopy Simulation Training: Results of 5 Years
of Experience
Pablo A Achurra, MD, Ruben Avila, MD, Rodrigo Tejos, Richard
Castillo, MD, Erwin Buckel, MD, Felipe Leon, MD, Fernando
Pimentel, MD, Fernando Crovari, MD, Nicolas Jarufe, MD, Julian
Varas, MD, Experimental Surgery and Simulation Center,
Department of Digestive Surgery, Pontificia Universidad Catolica de
Chile
Introduction: Minimally invasive surgery is currently the gold standard approach for many abdominal procedures but is associated to a long
learning curve. As an answer to growing patient safety concerns, advancing technology and working hour restrictions, simulation-based training is
becoming the recommended method to acquire basic and advanced surgical skills.
Objective: To present the results of a 5-years experience of a validated advanced laparoscopy simulation-based training program.
Methods: Assessment: All participants had to perform a hand-sewn laparoscopic jejuno-jejunostomy in a validated ex-vivo simulation model before
and after the training course. Time, Global and Specific rating scales (GRS and SRS), permeability and leakage of the anastomosis were recorded in
both evaluations. Data was analyzed using Wilcoxon and Mann-Whitney tests.
Simulation Based Training Program: The training program included 14 sessions of ascending difficulty, where the trainees learned to perform the
hand-sewn jejunojejunostomy in a progressive cumulative manner in an ex-vivo bowel model. In each session the trainees learned through
explicative videos, deliberate practice and effective feedback given by expert teachers. In order to complete the course the trainees had to perform
the anastomosis in less than 30 minutes, with good permeability, no leakage and optimal rating scores (GRS[20; SRS[15). If the trainees didnt
achieve this outcomes, they had two additional training/assessment sessions before failing the program.
Results: Between the years 2010 and 2015, 174 trainees underwent the simulation program, 77% male gender and 19% of other Latin-American
countries. At the end of the study period, 135 (78%) trainees had finished the training course and were considered for analysis. In the initial
assessment the mean time was 38 min (range: 20,4 60min), mean GRS 11,8 (range: 520) and SRS 9,2 (range: 415). Leakage was observed in
84% of the anastomosis.
After the training, mean time was 19,8 min. (range: 10,433min), mean GRS 23,1 (1925), SRS 18,3 (1520) and 100% permeable and without
leakage. Statistical difference was found for all variables when compared to initial evaluation (p\0,001). Two trainees failed the course (1,1%).
Twenty laparoscopic experts surgeons were measured in the same task, mean time was 22 min (15,827,4 min); mean GRS 24 (2325); and SRS 19
(1819). No statistical difference was found between experts and trainees final evaluation.
Conclusion: A structured advanced laparoscopy simulation program based on deliberate practice and effective feedback is able to train a great
number of surgeons with low failure rates and standards similar to experts.

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P152

Trial of the Flipped Classroom for Open Suturing and Simulated

Laparoscopic Cholecystectomy for Medical Students

How to be Impacted on Exposing Times and Dissecting Times

in Laparoscopic Sigma Resection by Surgeons Skills

Takashi Iwata, MD, PhD1, Masashi Akaike, MD, PhD1, Kozo

Yoshikawa, MD, PhD2, Jun Higashijima, MD, PhD2, Toshihiro
Nakao, MD, PhD2, Masaaki Nishi, MD, PhD2, Chie Takasu, MD,
PhD2, Mitsuo Shimada, MD, PhD2, 2Department of Digestive
Surgery, Institute of Biomedical Sciences, Tokushima University
Graduate School, 1Research Center for Education of Health
Bioscience, Institute of Biomedical Sciences, Tokushima University
Graduate School

Shigehiro Kojima1, Masaaki Ito2, 1Department of Surgery, Sainokuni

Higashiomiya Medical Center, 2Department of Colorectal Surgery,
National Cancer Center Hospital East

Background: In practice of medical students, it may not secure enough time for practical skill exercise due to explanation and a lecture to perform in
the beginning. Flipped classroom is a novel approach to learning where students watch lectures online and at their own pace, typically at home. Class
is then reserved for active learning exercises and interactive activities, which illustrate important concepts. The aim of this study was to investigate
the usefulness of flipped classroom for training of open suturing and simulated laparoscopic cholecystectomy.
Materials and Methods: Forty medical students in 5th grade of The Univ. of Tokushima were participated. They were divided into two groups;
conventional group (conv group: n=20) and flipped classroom group (flip group: n=20). Flip. group learned open suturing technique with Procedure
CONSULT on internet and procedure of laparoscopic cholecystectomy with original contents prior to suturing and/or laparoscopic training. Open
suturing training was performed with suturing simulator and simulated laparoscopic cholecystectomy was performed with Lap MENTOR IITM. Pretraining and post-training test, open suturing technique, simulated laparoscopic cholecystectomy technique and lecture time were investigated in both
open suturing training and simulated laparoscopic cholecystectomy.
Results: Flip. group showed a good result in both open suturing training and simulated laparoscopic cholecystectomy. Pre-training test score (20
points of perfect scores, average): 13.5 vs. 18.6 (conv. group vs flip. group), pre-training suturing evaluation (100 points of perfect scores, average):
62.6 vs. 91, Lecture time: 63 vs. 18.3 minutes. There was no difference between conv. group and flip. group in test score and suturing evaluation after
training.
Pre-training test score (100 points of perfect scores, average): 52.3 vs. 88.5 (conv. group vs flip group), pre-training operative evaluation (100 points of perfect
scores, average):53.2vs. 86.5, Lecture time: 17.2vs. 5.4 minutes. There was no difference between conv. group and flip. group in test score and operative evaluation
after training.
Conclusions: The training using the technique of the flipped classroom can shorten lecture time, save much time for practice, and make students
show a high understanding degree of surgical techniques.

P151
Transversus Abdominis Plane Blocks: A Pilot Study of Feasibility
and Ascension up the Learning Curve
Deborah S Keller, MS, MD1, Sergio Ibarra, MD1, Juan R FloresGonzalez, MD1, Nisreen Madhoun, DO1, Oscar I Moreno-Ponte,
MD1, Eric M Haas, MD, FACS, FASCRS2, 1Colorectal Surgical
Associates, Houston, TX, 2Colorectal Surgical Associates, Houston
Methodist Hospital, The University of Texas Medical School,
Houston, TX
Background: Transversus Abdominis Plane (TAP) blocks are advocated to reduce perioperative pain, narcotic requirements, and improve clinical
outcomes. However, no previous work has investigated the learning curve of TAP block placement. Our goal was to evaluate the learning curve for
TAP block placement in novices, identify issues that may impede successful placement, and their solutions.
Methods: Three novices were prospectively evaluated performing an ultrasound-guided TAP block in 10 consecutive patients undergoing
laparoscopic colorectal surgery. Operators were assessed on medication knowledge, set-up and placement, technical steps of the procedure, and
performance time. Set-up time, time for placement on each side, and total procedure time were compared to an experts time to determine efficiency
and competence. Feasibility was determined by proper knowledge of the medication and set-up, and placement within 2 standard deviations of expert
time. The main outcome measures were the procedures needed for competence and variables associated with increased coaching/procedure time.
Results: The 3 operators each performed 10 consecutive TAP blocks. In the patient sample, the mean age was 56.9 years (SD 15.6), and the mean body
mass index (BMI) was 30.9 (SD 5.79). Fifteen patients (50.0%) were obese (BMI[30), seven (23.3%) were super obese (BMI[35), and 15 had prior
abdominal surgery. The overall mean set-up time was 107.5 (SD 87) seconds, the right-side placement time was 131.8 (SD 60.3) seconds, the left-side
placement was 114.8 (SD 40.5) seconds, and total time 354 (SD 111) seconds. By the 2nd attempt, all operators were fluent in the medication and set-up.
At block 3, operators 1 and 3 reached competence in performance time; by block 4, all 3 operators reached time competence. After reaching competence,
outliers in procedure times were only experienced for extremes in BMI (\20 and [35). Additional coaching was needed in 4 patients with prior
abdominal surgery to decipher the correct planes.
Conclusions: Our pilot study demonstrates it is safe and feasible for novice surgeons to place TAP blocks. By 4 placements, novices were
competent, and continued to improve their times with experience. Extremes of BMI and prior abdominal surgery were found to impact procedural
time, and required additional coaching to facilitate placement in some cases. Given the promising results, further work on developing best practices
for education and implementation is warranted.

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Objective: The aim of this study was to clarify how differences of surgical ability between experts and novices had impacts on exposing times and
dissecting times in laparoscopic colectomy for sigmoid colon cancers.
Methods: We made up 3 sets of surgical groups by which thirty laparoscopic colectomies for sigmoid colon cancer were performed. Each group was
consisted as below; operator was done by expert surgeon and 1st assistant was done by novice surgeon in the first group (E/N), operator was done by
novice surgeon and 1st assistant was done by expert surgeon in the second group (N/E) and both were done by novice surgeons in the third group (N/
N). Ten laparoscopic sigma resections were performed by each group in the same periods. We also divided surgical procedures of whole
laparoscopic sigma resection into ten steps and measure exposing times and dissecting times in all the steps for all patients. We compared the
differences of these times among three groups and identified which surgical steps made the major differences among three groups in laparoscopic
operation for sigmoid colon cancers.
Results: No differences of clinical backgrounds were observed among three groups with respect to age, sex, body mass index (BMI), and tumor size.
Intraoperative outcomes including blood loss, and conversion rate were not significantly different. Total exposing times in the E/N, the N/E, and the
N/N groups were 319 (240571), 375 (141607), 754 (1572034) seconds (P = 0.048), and total dissecting times were 2091(13283916), 4099
(31256194), 4466 (30065407) seconds (P \ 0.001), respectively. There were the greatest differences between E/N and the others in dissecting
times in the surgical step of median to lateral dissection (p\0.001).
Conclusion: Exposing times were related with the existence of expert surgeon in laparoscopic surgical team regardless expert played an operators
role or an assistants role. On the other hand, dissecting times depended on an operators surgical ability and could reduce only by improvements of
operators skills especially in median to lateral approach in laparoscopic colectomy for sigmoid colon cancers.

P153
Plural Hands-on Seminar Program for Laparoscopic Surgery,
Especially for Residents
Hiroshi Kawahira, MD2, Naoyuki Hanari, MD1, Hisashi Gunji, MD1,
Hideki Hayashi, MD2, Hisahiro Matsubara1, 2Frontier Medical
Engineering, Chiba University, 1Frontier Surgery, Chiba University
Background/Purpose: It is desirable to practice laparoscopic training continuously for mastering laparoscopic surgery, especially for surgical
residents. We have been holding the hands-on seminar for residents about laparoscopic surgery sponsored by Chiba University Hospital and Chiba
Prefectural Government. Trainees need to come to the training center at Chiba University Hospital every three weeks, for three times in total. We
report the results of the questionnaire findings of the trainees.
Method: Our training programs are aimed for surgical residents. Each trainee has to attend the seminar for two hours every three weeks, three times
and six hours training in total to the training Center at Chiba University Hospital. The maximum capacity for attendee is three. The three expert
laparoscopic surgeons instructed each trainee. Our training program consisted of lectures about the basic skills for laparoscopic surgery and hands-on
seminar for suturing. We also used the 3D laparoscopy and the virtual simulator in the program during the program. Laparoscopic needle drivers and
training dry boxes were lent to the trainees during the program. After the program, we asked the trainees the nine items-questionnaires about the
training program.
Results: From November 20th, 2013, total 12 trainees were participated. All the trainees were completed the three times programs except that one
trainee had emergency surgery on the last seminar. The results of nine-items questionnaires were obtained from ten trainees. The length, usefulness
for the surgery, and schedule of each seminar was adequate. The task was slight difficult level for 4 trainees.
Conclusions: We kept the trainees motivated by plural seminar program.

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P156

Comparison of Learning Curves on the FLS and the Virtual Basic

Laparoscopic Skill Trainer (VBLAST): Pattern Cutting
and Ligating Loop Tasks

Surgical Skills Lab Improvement Project: A Cheap, Simple,

Effective Place to Start

Ali M Linsk, MD , Emily E Diller, BS , Kimberley R Monden, PhD ,

Ganesh Sankaranarayanan, PhD3, Woojin Ahn, PhD4, Christopher S
Awtrey, MD5, Suvranu De, ScD4, Daniel B Jones, MD5, Steven D
Schwaitzberg, MD6, Scott K Epstein, MD7, Jesse M Rideout, MD,
MPH7, Caroline GL Cao, PhD2, 1Beth Israel Deaconess Medical
Center, Cambridge Health Alliance, 2Wright State University,
3
Baylor University Medical Center at Dallas, 4Rensselaer Polytechnic
Institute, 5Beth Israel Deaconess Medical Center, 6University
at Buffalo School of Medicine and Biomedical Sciences, 7Tufts
University School of Medicine
Introduction: VBLaST is a virtual reality-based simulator developed to replicate the FLS tasks. This study
compared the learning curves of the pattern-cutting (PC) and ligating-loop (LL) tasks on the FLS trainer box
with those on the VBLaST.
Methods and Procedures: Forty-eight medical students were randomly assigned to one of six conditions:
control PC (no training), training FLS-PC, training VBLaST-PC, control LL (no training), training FLS-LL,
and training VBLaST-LL. The training subjects performed 150 trials over a three-week training period.
Pretests, post-tests (immediately following training trials), and retention tests (two weeks after post-tests) on
both FLS and VBLaST for the assigned task were also done.
Non-linear regression analysis was used to fit an inverse curve to the learning curve data for both completion
time and normalized score. The average learning rate was calculated for each task on both simulators, and
the performance plateau on the learning curves was determined. The learning plateau is the time to task
completion or score at the asymptote of the curve and the learning rate is the number of trials required to
reach 90% of the plateau.
Results: Pattern-cutting task: The learning curves on the FLS and the VBLaST simulators were similar.
Subjects reached the performance plateau at similar rates based on time to task completion (74.72 sec, 21
trials on FLS; 90 sec, 22 trials on VBLaST), and task score (77.93 score, 10 trials on FLS; 74 score, 10 trials
on VBLaST).
Ligating-loop task: The learning curves on the FLS and the VBLaST simulators were also similar. Subjects
who trained on the FLS reached a lower performance plateau (35.51 sec) than the VBLaST-trained subjects
(29.94 sec), but at a faster rate (28 trials vs. 37 trials). Based on their scores, the FLS-trained subjects were
able to reach a slightly higher score at performance plateau (101.11 score, 7 trials on FLS; 88.71 score, 8
trials on VBLaST) at the same rate.
Conclusions: Virtual reality training using the VBLaST simulator is equally effective in fostering laparoscopic skill acquisition when compared to the gold standard of the FLS box trainer. VBLaST offers
additional advantages such as real-time feedback, instant scoring, and provides the ease of repeated trials
without needing expensive consumables and trained proctors.

P155
A Novel Hiatal Hernia and Fundoplication Simulator Results
in Significant Trainee Skills Improvement
Tomokazu Kishiki, Brittany Lapin, JoAnn Carbray, Michael B Ujiki,
NorthShore University HealthSystem Grainger Center for Simulation
and Innovation
Background: Simulation training in laparoscopic surgery has been shown to improve surgical performance;
however, advanced laparoscopic surgery training has not been yet established. The purpose of this study was
to develop a new system of laparoscopic surgery training for hiatal hernia and fundoplication.
Method: A laparoscopic training box model for hiatal hernia repair and fundoplication was developed. Nine
general surgery residents participated in a 4-week dedicated skills curriculum covering five advanced
laparoscopic procedures: (1) Equipment, Positioning and Trocar Placement, (2) Ability to Close Hiatus, (3)
Fundoplication Set up, (4) Fundoplication Suture Placement and (5) Ability to Manipulate Instruments. The
training system was composed of a pre-test, mentored instruction, practice, and post-test. Residents completed a confidence survey pre- and post-test, and each task was scored by the resident and an evaluator.
Paired t-test assessed differences pre- and post, and intraclass correlation coefficient (ICC) was used to
evaluate reliability.
Result: Evaluators rated residents as improving significantly pre- to post-training on all five tasks (p\0.01
for all). Residents self-evaluated themselves as improving significantly on (1) equipment, positioning and
trocar placement (p\0.01), (2) ability to close hiatus (p=0.02), and (5) ability to manipulate instruments
(p\0.01). They improved on the other two tasks but the difference did not reach statistical significance ((3)
set up of fundoplication (p=0.10) and (4) fundoplication suture placement (p=0.051)). The pre-training test
showed moderate to strong reliability between residents and evaluators with agreement on all five tasks (ICC
[0.6 for all but (3) set up of fundoplication (ICC=0.49, p=0.07)). The post-training test showed moderate to
strong agreement between residents and evaluators for (1) equipment, positioning and trocar placement
(ICC=0.67), (2) ability to close hiatus (ICC=0.86), and (3) set up fundoplication (ICC=0.77), however (4)
fundoplication suture placement and (5) ability to manipulate instruments showed poor agreement
(ICC=0.06 and 0.23, respectively). The residents improved their confidence in performing hiatal hernia and
fundoplication on all 12 questions, with 10 of the 12 confidence questions showing significant improvement.
In resident evaluation, all residents found the system very helpful. 33% of residents rated the system as
difficult, with all residents indicating they would be comfortable doing the procedure independently.
Conclusion: Our simulation system is effective and useful for training residents in hiatal hernia and
fundoplication.

Jawad T Ali, MD1, Brent Ford2, John Uecker, MD1, 1University

of Texas at Austin, 2University of Texas Medical Branch
Introduction: Practice of skills outside of the operating room is an integral and evidence based part of
surgical training. Our hypothesis is that our surgical skills lab was not reaching its potential due to lack of
access, disorganization, and dissatisfaction among surgery residents. We wanted to improve the functionality and usage of the lab as well as track outcomes.
We proposed a three-pronged approach:
1) Improve access
2) Organize equipment around ACS task-based workstations
3) Strategically advanced trainers
Methods: We conducted a pre-intervention survey among all 14 surgical residents (3 per class with the
study author excluded). Access was improved by placing keys to the lab along with a sign-out sheet.
Extraneous equipment was removed and existing equipment was neatly organized into 7 clearly defined
workstations: Knot tying, suturing, abdominal wall closure, intestinal anastomosis, vascular anastomosis,
chest tube and central line placement, and laparoscopy. A post-intervention survey was conducted at one
month after the changes were instituted.
Residents were asked about their overall satisfaction, if they would recommend the lab to others, if they used
it outside of scheduled sessions, and if they were satisfied with ease of access. They were also asked about
their satisfaction with regards to training each of the previously described skills. Agree or Strongly agree
were marked as positive responses.
Results: Areas that received a dedicated workstation had the largest increase in satisfaction. Vascular
anastomosis increased from 43% to 86% and laparoscopic skills from 36% to 79%. Also, simply having a
key that was always available dramatically improved issues with accessibility with a 43% to 93% increase.
Basic skills like knot tying and suturing were shored up from 71% to 100%. Their likelihood to recommend
our lab to other residents increased from 7% to 50%.
Use of the lab outside of scheduled training had some improvement, 36% to 57%. Our post-intervention
survey showed areas that had further room for improvement were lab usage outside of didactics as well as
advanced laparoscopic maneuvers.
Conclusion: Removing clutter and adding instantly usable workstations were a large part of the improved
overall satisfaction. Increased lab usage will be an eventual culture change. An effective approach to
enhancing skills lab use and satisfaction among surgery residents consists of organizing equipment around
task-based workstations, making the lab easy to access at all times, and strategically filling in gaps in
advanced training equipment.

P157
Twitter Use at Sages Annual Meetings 20102015
Andrew S Wright, MD1, Alejandro Rodriguez-Garcia, MD1, Jason C
Levine2, Heather L Evans, MD1, 1University of Washington, 2Society
for American Gastroenterologist and Endoscopic Surgeons
Over the past 5 years there has been a dramatic rise in the use of social media by surgeons, allied personnel,
and patients during the SAGES Annual Meetings. The aim of this study is to explore changes in the rate of
Twitter utilization as well as to determine how Twitter is being used for educational, social, or other
purposes with regards to the SAGES Annual Meeting.
Methods: Tweets were searched and archived from twitter.com for the hashtags #SAGES2010,
#SAGES2011, #SAGES2012, #SAGES2013, #SAGES2014, and #SAGES2015. For the years 2014 and
2015 the total number of participants and the number of hashtag impressions were obtained from the
Healthcare Hashtag Project (www.symplur.com). Participants are defined as all twitter users that tweet,
retweet, or favorite tweets. Impressions are defined as the number of Twitter users exposed to tweets on a
subject multiplied by the number of tweets to which each user is exposed. Tweets from 2015 were analyzed
for content. Descriptive statistics were generated in Microsoft Excel.
Results: The number of tweets related to SAGES Annual Meetings increased from 2 in 2010 to 1256 in
2015, with the number of individuals posting tweets going from 1 to 189 (Table 1). Total participants
increased from 278 in 2014 to 522 in 2015. The total number of impressions rose from 1,152,491 in 2014 to
5,354,291 in 2015. Over the five years studied, 42% of all tweets were retweeted at least once while 37%
were marked as favorite. In 2015 the most common category of tweet was discussion of meeting content
(567 tweets) followed by administrative (271), social (253), and industry/marketing (94). Among the discussion tweets, specific content areas included: Surgical Education (112), Foregut (99), Hernia (65),
Outcomes/Patient Safety (51), Hepatobiliary (49), Career Development (47), Colorectal (39), Global Health
(27), Bariatrics (25), and Pediatric Surgery (11).
Discussion: Use of Twitter during and around the SAGES Annual Meeting has expanded dramatically over
the last 5 years. As an educational and communication tool, Twitter is used for many purposes during the
Annual Meeting, most notably discussion of medical knowledge. This presents an opportunity for enhanced
learning and dissemination of knowledge as well as for outreach to surgeons and other interested parties who
may not be able to attend the meeting. The SAGES organization should continue to support and encourage
discussion via social media.

Table 1 .

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P160

From the Operative Field to the Film Room: Surgeons

Encouraged by Video Review and Expert Coaching

Perception Versus Reality for MIS Fellows: A Survey of Current

Fellowship Council Trainees

Todd A Jaffe, BBA, Steven J Hasday, BS, Meghan C Knol, MS, Jason
C Pradarelli, MS, Justin B Dimick, MD, MPH, University
of Michigan

Jeffrey R Watkins, MD1, Aurora D Pryor, MD2, Frances Lewis1,

Michael S Truitt, MD1, D Rohan Jeyarajah, MD1, 1Methodist Dallas
Medical Center, 2Division of Bariatric, Foregut and Advanced
Gastrointestinal Surgery, Stony Brook University

Introduction: Surgical outcomes vary considerably across hospitals and individual surgeons. It has been demonstrated that expert assessment of surgeons skill using
intraoperative videos correlates strongly with surgical outcomes. The current landscape of
intraoperative video review among surgeons is largely unknown. Our aim is to understand
how surgeons currently use intraoperative video and determine their interest in being
assessed by a surgeon trained to serve as a coach.
Methods and Procedures: 77 faculty in the Department of Surgery at a large Midwestern
Academic Health Center were invited to participate in a 22-question on-line survey via
email. Survey respondents were asked to indicate if they have ever used intraoperative
video review to critique their own surgical performance. Based on response, respondents
were asked to indicate either how helpful they believe video is, or how helpful they believe
video would be. All respondents were asked to indicate how helpful they perceive it would
be to have a surgeon trained as a coach review their intraoperative video.
Results: The survey response rate was 71% (55/77). 18/55 (33%) of respondents have
personally reviewed their own intraoperative videos, while 37/55 (67%) have not. 78% (14/
18) of those that have used personal video review in the past considered it to be helpful
(indicated by responses of either somewhat helpful or very helpful on a 5-point Likert
scale). Among respondents who had not reviewed their own intraoperative videos, 62% (23/
37) perceived it to be helpful. Only 11% (4/37) believed video review would be unhelpful
(indicated by responses of either very unhelpful or somewhat unhelpful).
82% (45/55) of respondents believe that having a surgeon trained as a coach review and
critique their intraoperative videos would be helpful. Conversely, only 2 respondents
(3.6%) indicated that they believe coaching would be unhelpful.
Conclusion: Personal use of intraoperative video to review and critique surgical performance is not commonly used by practicing surgeons. However, a vast majority of surgeons
perceive personal video review as helpful, regardless of previous use. Surgeons also largely
feel that having a surgeon trained as a coach review intraoperative videos would be helpful.

Introduction: The aim of our study is to determine minimally invasive trainee motivation
and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one
of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship. As general surgery evolves,
it is important to understand resident motivation in order to better prepare them for a
surgical career.
Methods and Procedures: A survey invitation was sent to current trainees in the Minimally Invasive pathway through the Fellowship Council. The participants were asked to
complete a web-based questionnaire detailing demographics, experiences preparing for
fellowship, motivation in choosing an MIS fellowship and expectations for surgical practice
after fellowship.
Results: Sixty-four MIS trainees responded to the survey out of 160 invitations (40%). The
Fellowship Council website, mentors and fellows were cited as the most helpful source of
information when applying for fellowship. Trainees were active in surgical societies as
residents, with 78% membership in ACS and 60% in SAGES. When deciding to pursue
MIS as a fellowship, the desire to increase laparoscopic training was the most important
factor followed by a desire to increase professional competitive advantage with 93% of
respondents considering these important or very important. The least important reasons
cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. When choosing specific fellowship programs, trainees cited large case volume and
diversity, program type, and strength of faculty as the most important factors. The majority
of trainees believed their exposure to laparoscopy compared to other residents was above
average (83%) and that their laparoscopic skill set was above that of fellow residents (81%).
After fellowship, the majority of respondents planned on working with residents in some
capacity (78%), but only 20% plan on practicing in an exclusively academic environment.
The most desired post-fellowship employment model is hospital employee (46%) followed
by private practice (27%). Most fellows believe that their actual practice will be less
directly related to their fellowship training than their ideal practice. Almost all fellows plan
on marketing themselves as MIS surgeons (90%) when in practice.
Conclusions: Residents who choose MIS as a fellowship have a strong exposure to
laparoscopy and want to become specialists in their field. Mentors and surgical societies
including ACS and SAGES play a vital role in preparing residents for fellowship and
practice.

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P161

The Effect of E-Learning vs Didactic Lectures on Knowledge

in Basic Laparoscopic Skills and Advanced Suturing
in Developing Countries

Resident Attitudes Toward Robotic Surgery Across Surgical

Specialties

Sujith Wijerathne1, Eva Lourdes1, Alfred A Buenafe2, Asim Shabbir1,

Rishav Shrestha1, Davide Lomanto, Prof1, 1Minimally Invasive
Surgery Centre, Department of Surgery, National University Health
System, Singapore, 2Batangas Medical Centre, Philippines
Introduction: Knowledge on basic laparoscopic skills and advanced suturing is an essential
component of the residency training in general surgery. The advancement of science has
given us multiple platforms to deliver and acquire knowledge. E-learning is increasingly
gaining popularity among both residents and lecturers due to its easy accessibility and
reproducibility. But residents in developing countries may have limitations with access to
basic laparoscopic skills training either by simple lectures and/or e-learning. E-learning
may be superior to conventional lectures because its accessible any time. The improvement
of connectivity is helpful in providing more e-teaching to surgical residents in remote areas.
Methods: We created an online e-learning platform at http://coursemed.com in which
different modules focus on basic laparoscopic skills and advanced suturing. An assessment
test was performed before and after completion of the course and/or lectures using 20
predefined multiple choice questions (MCQs). 84 surgical residents from Nepal, Myanmar,
Cambodia, Sri Lanka, and India were enrolled for the e-learning exercise.
Results: 75(89.3%) took part in the pre-test and 71(84.5%) took part in the post-test while
only 63(75%) of them completed both pre and post-tests. Out of the 63 residents who
completed both tests, 12(19%) had no change in test scores, 11(17.5%) had poorer test
scores and 40(63.5%) had improved scores. The mean pre-test and post-test scores were
67.1(11.97) and 77.1 (11.94) respectively and this was statistically significant
(p\0.0001).
Conclusion: During an era where access for electronic data is widely available, e-learning
can be effectively incorporated in to the residency curriculum, which could help improve
knowledge of residents on selected core topics.

123

Abdul Q Alarhayem, MD, Michelle Savu, MD, Udit Jain, MS,

UTHSCSA
Background: The field of robotic surgery has undergone substantial growth and change
over the last decade. The purpose of this survey was to study the current experiences,
attitudes and opinions of residents across surgical subspecialties in the United States
towards robotic surgery.
Methods: Eighty five general surgery, urology, and gynecology residents attending didactic
conferences were asked to complete a questionnaire regarding their experiences with
robotic surgery.
Results: Sixty one of the surveyed residents across PGY levels responded. Forty eight
percent of respondents reported [ 50 surgical procedures were performed robotically in
their specialty in the last year, while 25% cited more than 100 procedures. This did not vary
across surgical subspecialties. Fifty two percent of respondents reported working with 34
staff surgeons who performed robotic procedures in their specialty, while 36 % reported
working with more than 5 surgeons. 80% of urology residents felt robotics would play an
important role in their post-residency practice, compared to 45% of gynecology residents,
and 38% of general surgery residents. 88% of residents either agreed or strongly agreed that
having the robotic surgery skillset would make them more attractive to future employers,
and 68% agreed or strongly agreed that it would improve patient care. Despite the majority
of residents (71.7%) reporting their current experience with robotic surgery training to be
either poor or below average (did not vary significantly across specialties or PGY level),
less than 20% reported interest in pursuing post-graduate robotic training. 62% of residents
felt the lack of formalized training was the primary barrier to being able to perform robotic
surgery and less than 15% of residents cited a lack of interest.
Conclusion: The majority of residents across surgical subspecialties are exposed to robotic
surgery in the operating room. Many feel robotics will play a role in their future practice,
yet report their current experience to be poor or below average. Most residents find the
absence of formalized training during residency to be the primary barrier to achieving
proficiency.

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P164

Long Term Followup of a Validated Robotic Surgery Training

Program

3D-Printed Laparoscopic and Robotic Surgical Simulation

and Navigation System Using Bio-Elastic Wet Hemorrhagic
Organ Replica

Sam E Kirkendall, MD, Aimee K Gardner, PhD, Robert V Rege, MD,

University of Texas Southwestern Medical Center
Introduction: A comprehensive, proficiency-based robotic training program was previously developed,
validated, and integrated into the curriculum at our large teaching institution. The purpose of this study was
to query past participants regarding the usefulness of the training for their practice in order to determine how
to further improve and expand the curricula.
Methods and Procedures: An anonymous 34-item online survey was developed and submitted to past
participants of whom we had current contact information.
Results: Forty-seven of the 101 (46.5%) previous trainees responded, consisting of graduates in General
Surgery (N=28), Urology (N=13), Thoracic Surgery (N=5) and Neurosurgery (N=1). Eleven respondents are
still in training. Participants reported current practice setting as private practice (29.3%), academic institution (51.2%), or community hospital (19.5%). The majority of respondents (83%) reported the curriculum
as their first robotic training experience. Only 10 reported undergoing any additional training since completing the course (including fellowships). Approximately one-third (38%) perform 0 robotic cases per year,
whereas 19% perform 110/year, 27.6% perform 1150/year, 6.3% perform 51100, and 8% perform more
than 100 robotic cases per year. When asked to rate the usefulness of each of the nine individual tasks to
their current practice on a five-point scale, respondents rated clutch and camera movement (3.83), simple
suture (3.78), and running suture (3.75) as the most useful modules. A majority (85%) was not familiar with
any other robotic training curricula, but 49% were interested in pursuing additional robotic training. Almost
all respondents (97%) felt the training program should be continued for surgical trainees and 44% indicated
that robotic training should be offered to ancillary staff members. Of those who were aware of credentialing
requisites at their institution, 48% indicated that this training program was sufficient to meet those
requirements. Suggestions for improvement included additional training in port placement and docking,
integration with the backpack trainer, live tissue suturing/pig lab, additional suture practice including tying
knots under tension, and more feedback.
Conclusions: This robotic training program is an important component in preparing trainees for independent
practice that includes robotic surgery. These trainees did not frequently complete further training and
completion of the program was often acceptable for credentialing at their current institutions, emphasizing
the importance of a comprehensive initial program. The program might be improved by integrating the
backpack virtual reality training system into training, adding additional suturing with possible live tissue
model, and providing more feedback.

P163
Proficiency-Based Simulation Training for FLS and FES:
A Dedicated Two-Week Simulation Curriculum for Junior
Surgery Residents
Yangseon Park, MD, Amy Cha, MD, FACS, Gary Korus, MD, FACS,
Christopher Neylan, BA, Jon Morris, MD, FACS, Daniel Dempsey,
MD, FACS, Noel Williams, MB, BCh, MCh, FRCSI, FRCS,
Kristoffel Dumon, MD, FACS, Perelman School of Medicine
University of Pennsylvania
Deliberate learning through simulation training is an essential component of a surgical residency program.
The American Board of Surgery requires residents to complete Fundamentals of Laparoscopic Surgery
(FLS) and Flexible Endoscopy Curriculum (FEC) training for board certification. However, due to time
constraints placed on junior surgical residents, finding time for simulation practice is difficult. The lack of
structured and program-tailored curricula utilizing laparoscopic and endoscopic training poses a challenge to
residents who wish to maximize the value of their simulation experience. To address these challenges, we
designed a dedicated two-week simulation curriculum for junior residents.
Nine PGY-2 residents were individually assigned to a four-week training period. Two weeks were spent on
simulation and two weeks on a clinical endoscopic rotation. In the beginning of the program, personalized
objectives were identified. Then, an individualized curriculum was developed wherein half of the simulation
training time was dedicated for laparoscopic and the other half for endoscopic simulation training. Each
trainee received a formative assessment by a dedicated surgical faculty member during his or her simulation
practice. The content of the curriculum was built around didactic materials provided by the FLS and FEC, as
well as peer-reviewed curriculum pathways for virtual reality training designed to help residents achieve
proficiency-based benchmarks.
An individual curriculum was developed for each resident by tailoring a standard content framework to the
particular residents needs. The two-week simulation curriculum included focused tasks such as the reading
of material pertinent to endoscopic surgery, and the performing of simulated cases on a virtual reality
trainer. Summative assessment followed each block. After the laparoscopic training block, all trainees
reached passing scores of the FLS exam. Completion of simulated endoscopic training during designated
simulation time was followed by a two-week clinical endoscopy rotation during which they were evaluated
by faculty. To date, five residents who have completed the simulation curriculum and clinical endoscopy
rotation passed the Fundamentals of Endoscopy Surgery test.
A structured, individually tailored, proficiency-based simulation curriculum was well received by junior
residents and faculty. Dedicated time without clinical obligations enabled junior residents to focus on
improving their technical skills in laparoscopic and endoscopic procedures. This simulation curriculum was
designed to be feasible for varying degrees of resource and staff availability. A balanced curriculum which is
structured and customizable to accommodate individual needs is ideal. Resident and attending assessments
will be tracked over time to determine the impact of the curriculum.

Maki Sugimoto, MD, PhD, Kobe University

The surgical simulation and training in the actual operating room are generally limited to a relatively small
number of procedure types, though surgeons can easily apply the lessons from one surgery to many others.
To overcome this limitation, we developed a 3D-printed laparoscopic surgical simulation and navigation
system using anatomically accurate bio-elastic wet hemorrhagic organ replica from MDCT data of a
patients skin, bones, blood vessels and abdominal organs. Our hybrid 3D imaging and 3D-printed injection
molding technology allowed to manufacturing bio-elastic abdominal wall replica. Based on patient-specific
DICOM data from MDCT, after generating its surface polygons using OsiriX application, the multi-material
inkjet 3D printer created life-size copies of the 3D organs such as liver, biliary system, pancreas, blood
vessels, fat, and abdominal cavity. The replicas were manufactured bio-elastic by simultaneous jetting of
different types of materials and injection molding the polyvinyl alcohol (PVA) and water. Each organs
mold model was given an injection of a synthetic resin that helps make it feel wetter and more lifelike for the
surgeon. We evaluated the feasibility of this system in 30 laparoscopic and robotic surgery simulations and
navigation. We programed a printer to create clear models made from acrylic resins that allowed us to
visualize and understand the complex internal organ structures and blood vessels or the exact tumor
locations. It allowed these models realistic stand-in for ultrasonic diagnosis, hepatic intervention and surgical procedure such as cutting, suturing and ligation.
The personalized bio-elastic wet organ replicas were useful for visible and tangible surgical simulation and
navigation to plan and guide the successful lap surgeries. With the wet model, surgeons can experience the
softness of organs and see them bleed, to help us in practice on lifelike models before stepping into real
surgery. Using abdominal cavity replica, there was a place for using synthetic models in realistic surgical
situation including laparoscopic and robotic surgeries. The use of these replicas reduced the length of the
operation and provided better anatomical reference tools for tailor-made navigation surgery, consequently
helping to improve training for the operating room staff, students, and trainees.
These could overcome the limitations of the conventional image-guided laparoscopic navigation. Its
combines the advantages of conventional 3D modeling and precise virtual 3D planning in personalized
surgical simulation and navigation.

P165
Use of a Formative Feedback Tool in Place of an Expert Coach
in Laparoscopic Suturing Training: A Randomised NonInferiority Trial
Amani G Munshi, MD1, Yusuke Watanabe, MD1, Katherine
McKendy, MD1, Yoichi M Ito, PhD2, Gerald M Fried, MD, FRCSC,
FACS1, Melina C Vassiliou, MD, MEd, FRCSC1, Liane S Feldman,
MD, FRCSC, FACS1, 1McGill University Health Center,
2
Department of Biostatistics, Hokkaido University Graduate School
of Medicine
Introduction: The need for a coach to provide feedback and remediation during simulation training is a
barrier to widespread adoption. We developed a formative feedback tool (FFT) to provide trainees with
specific, formative feedback about their laparoscopic continuous suturing skills. The objective of this study
was to compare suturing performance after self-directed training using the FFT with training under a coach.
Methods and Procedures: In this randomized, open-label, non-inferiority trial, general surgery residents
able to perform the FLS intracorporeal single suturing task in B 225 seconds were given 1 training session
on a continuous suturing model with a coach and then introduced to the FFT and an accompanying videobased interactive learning tool (VILT). They were randomly assigned to receive 2 additional training
sessions with FFT/VILT plus a coach (C) or self-training with FFT/VILT alone (NC). Performance was
evaluated by a blinded evaluator pre- and post-training using time/error scores and the FFT. The primary
outcome was change in time/error scores from baseline, with a 20% non-inferiority margin. The secondary
outcome was change in FFT score.
Results: Nineteen residents (10 C, 9 NC) completed training (median PGY: 4). Baseline characteristics were
similar in both groups, as were median (IQR) time/error scores at baseline (527[343586] vs. 436[230633],
p=0.21) and after 3 training sessions (709[626769] vs. 628 [461751], p=0.21). Similarly, FFT scores for
the C and NC groups were similar at baseline (27[18.330.5] vs. 25[22.028.5), p=0.97) and after training
(37[3638] vs. 36[3438], p=0.43). On subgroup analysis, the C group FFT scores (27[18.330.5] vs.
37[3638], p=0.002) and time/error scores (527[343.3586.3] vs. 708.5[626769.3], p=0.0002) both
improved significantly over the duration of the study, with a trend in that direction for the NC group.
Conclusion: For residents, improvement in performance on an advanced laparoscopic suturing task was
similar using FFT/VILT as feedback alone compared to those who also had coached sessions. Although
there is evidence to support the validity of the FFT as a measure of suturing skill, this study suggests that it
also provides meaningful and usable feedback. Coaching when possible, may have a slight benefit over selftraining with the FFT, however, the FFT is an effective alternative when expert coaches are not available.

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The Impact of Structured Intensive Laparoscopic Training

Course on Residents Operative Performance in Animal Lab

Single-Incision Laparoscopic Appendectomy as a Teaching

Procedure: A Single-Center Experience with More than 200
Procedures

Iman Ghaderi, MD, MSc1, Tung Tran, MD2, Julia Samame, MD1,
Hany Takla, MD1, Rose Ibrahim, MD1, Hannah Loebl, BA1, Carlos
Galvani, MD1, 1University of Arizona, 2MedStar Health
Introduction: Simulation-based training has gained popularity in recent years. The objective of this study was to examine the
impact of an intensive laparoscopic training course on residents performance in animal lab.
Methods and Procedures: Surgical residents from a teaching Hospital participated in a 3- day structured intensive laparoscopic
training course. The junior residents (PGY12) performed 2 basic (cholecystectomy and incisional hernia repairs) and senior
residents (PGY35) performed 3 advanced laparoscopic procedures (Nissen fundoplication, splenectomy, and low anterior colon
resection) on live pigs. Each resident performed the same procedure twice in two consecutive days. Their operative performance was
assessed using validated assessment tools including the Global Operative Assessment of Laparoscopic Skills (GOALS) for general
laparoscopic skills and procedure-specific skills including GOALS-Incisional Hernia, Operative Performance Rating System
(OPRS) for cholecystectomy, colectomy and a rating scale for Nissen fundoplication. The assessments were completed by faculty
and residents (self-assessment) after each procedure. The Wilcoxon rank test was used to examine the effect of training on resident
performance after one repetition. Statistical significance was considered at p \ 0.05.
Results: Forty surgical residents (20 junior and 20 senior residents) participated in four courses in 2015. Residents general
laparoscopic skills improved in incisional hernia repair and Nissen fundoplication (p \0.05). Their scores also improved in
procedure specific ratings in cholecystectomy, incisional hernia repair and low anterior colectomy (p\ 0.05) (Table 1). The scores
between faculty and resident assessments were moderately to strongly correlated (r[0.6)
Conclusion: Trainees show significant improvements in performance in general laparoscopic and procedure specific skills after an
intensive laparoscopic training course. These effects are reproduced through a wide range of laparoscopic procedures. Future studies
are needed to examine the skill retention and number of sessions required to achieve competency.

Table 1

Procedure

General laparoscopic skills Improvement

day 1 to day 2 (p value)

Masaki Wakasugi, Mitsuyoshi Tei, Toru Masuzawa, Kenta Furukawa,

Yozo Suzuki, Kentaro Kishi, Masahiro Tanemura, Hiroki Akamatsu,
Osaka Police Hospital
Purpose: To evaluate resident performance and patient outcomes in patients undergoing single-incision laparoscopic appendectomy
(SILA) by comparing resident-performed and staff doctor-performed procedures.
Methods: A retrospective analysis of 202 patients who underwent SILA from May 2009 to May 2015 at Osaka Police Hospital was
performed. The residents in the study were distributed among all postgraduate years from three to five years. The staff surgeons in
this study had advanced minimally invasive fellowship training and had routinely performed single-incision laparoscopic surgery.
All operations performed by the residents were performed under the guidance of fully trained staff surgeons.
Results: The residents operated on 77% (156/202) of patients undergoing SILA in our department. The mean age in the resident and
staff surgeon groups was 38 years (range 684 years) and 49 years (range 889 years), respectively (p\0.05). The patients operated
by the staff surgeon had significantly higher rates of complicated appendicitis (61%, 28/46) than patients treated by the residents
(40%, 62/156) (p \ 0.05). There were no significant differences between the two groups with regard to the patients sex, BMI, and
ASA. The mean operative time in the resident and staff surgeon groups was 76 min (range 26243 min) and 111 min (range 32240
min), respectively (p\0.05). The mean bleeding volume in the resident and staff surgeon groups was 16 mL (range 0800 mL) and
49 mL (range 0400 mL), respectively (p \ 0.05). The conversion rate to a different operative procedure was 3% (5/156) of the
patients in the resident group and 13% (6/46) in the staff surgeon group, respectively (p \ 0.05). Five cases in the resident group
were converted: three to multi-port LA and two to open surgery. Six cases in the staff surgeon group were converted to multi-port
LA. Perioperative complications were seen in 9% (14/156) of the patients in the resident group and 20% (9/46) of the patients in the
staff surgeon group (p\0.05). The mean postoperative hospital stay was 6 days (range 223 days) for the resident group and 8 days
(range 223 days) for the staff surgeon group (p \ 0.05).
Conclusions: SILA could be useful as a teaching procedure for the residents with adequate selection of patients and the guidance of
a fully trained staff surgeon.

Procedure specific skills Improvement

day 1 to day 2 (p value)

Rater

Faculty

Self

Faculty

Self

Cholecystectomy

0.63

0.91

0.01*

0.43

Incisional hernia repair

0.01*

0.01*

0.01*

0.18

Nissen fundoplication

0.04*

0.01*

0.054

0.07

Splenectomy

0.26

0.12

N/A

N/A

Low Anterior Colectomy

0.1

0.01*

0.03*

0.01*

* P value\ 0.05

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P167
A Data-Based Self-Training Guideline for Laparoscopic Surgical
Skills According to the Operative Experiences
Morimasa Tomikawa, MD, PhD, FACS1, Munenori Uemura, PhD1,
Tomohiko Akahoshi, MD, PhD1, Kazuo Tanoue, MD, PhD, FACS2,
Makoto Hashizume, MD, PhD, FACS1, 1Kyushu Univeristy, 2Ueno
Hospital
Aim: To propose a data-based self-training guideline for laparoscopic surgical skills according to the operative experiences.
Methods: The trainees of the 2-day standardized laparoscopic surgical training program were divided into three groups according to
their operative experiences of laparoscopic surgery; group N (novices, n=276), group M (intermediates, n=161) and group E
(experts, n=145). Their skills for laparoscopic surgery were assessed by our originally-developed skills assessment task in box
trainer with suturing and knot tying. Times taken for suturing and knot tying, the number of completed sutures, and the errors during
suturing were recorded. A three-dimensional electromagnetic tracking system (AURORA; Northern Digital Inc. Canada) was used
to analyze the path lengths and the speeds of the hand motions. The data at the beginning of the program were compared with those
at the end, and did among the 3 groups.
Results: In all 3 groups (N/M/E), suturing and knot tying times at the end of the program (121.4/111.1/99.6 seconds) were
significantly shorter than those at the beginning (209.7/187.3/164.2) (all P \ 0.001). The significant differences of the times among
the 3 groups each other at the beginning remains even at the end (P \ 0.05). While the significant differences of the times spent at
the first suture and knot tying among the 3 groups at the beginning (P\0.05) remains at the end of the program, the significant
differences of the times spent at the second knot tying among the 3 groups at the beginning (P\0.05) disappeared at the end. The
significant differences of the number of completed sutures among the 3 groups at the beginning (2.0/2.4/3.1) remains at the end of
the program (4.0/4.5/4.9) (P\0.05). Errors increased in all 3 groups at the end of the program. In group N, the path length of the left
hand significantly increased at the end of the program (P \ 0.05). In group M, the path length of the right hand significantly
increased at the end (P \ 0.05). However, in group E, the path lengths of both hands did not change.
Conclusions: The amount of surgeons experiences reflects the changes of the speeds and the qualities of suturing and knot tying
after the short-term training. While novices should focus on non-dominant hand motion, intermediates should focus on bi-hand
motions. It is feasible to propose a data-based self-training guideline for laparoscopic surgical skills according to the operative
experiences.

123

Laparoscopic Training Leads to Acquisition of Sophisticated

Technical Skills Superfluous for the Robotic Environment:
Results of a Randomized Trial on Virtual Reality Simulation
Platforms
Sergio E Alonso Araujo, MD, PhD1, Alexandre B Bertoncini, MD1,
Lucas A Horcel1, Victor E Seid, MD, PhD1, Sergio C Nahas, Md,
PhD1, Ivan Cecconello, MD, PhD1, Conor P Delaney, MD, PhD2,
Luiz Augusto C DAlbuquerque, MD, PhD3, 1Department
of Gastroenterology, Division of Colon and Rectal Surgery,
University of Sao Paulo Medical School, Sao Paulo, Brazil,
2
Department of Surgery, Case Western Reserve University School
of Medicine, 3Department of Gastroenterology, Discipline of Organ
Transplantating of the Digestive Tract, University of Sao Paulo
medical School, Sao Paulo, brazil
Purpose: Training surgeons to proficiency in laparoscopic and in robotic surgery is challenging. Virtual reality (VR) laparoscopic
and robotic simulator training improves patient safety and operating room efficiency. However, data comparing the impact of VR
training on skills acquisition remain scarce. In the present study, we aimed at determining how does training in a robotic VR
simulation platform compare to training in a laparoscopic VR simulator regarding which modality improves skills acquisition more
effectively.
Methods: Sixty-three medical students (2nd to 4th year) were randomly assigned to a 4-hr intensive proctored simulator training
session in a robotic (Mimic DV Trainer) or laparoscopic (Simbionix Lap Mentor) VR simulator. All participants were given a
tutorial on using both laparoscopic and robotic simulators and participated in a warm-up. After randomization, students practiced to
proficiency in four pre-determined skill-matched modules on each simulator. After training completion, all students executed two
unpractised predetermined test tasks, one in each simulator (the first test module was taken in the simulator they have trained, the
second was completed in the simulator they have not trained). The primary outcome measures were comparative performances
between the two groups of participants, based on simulator scores, in both simulators. For the test module undertaken in the
laparoscopic simulator, 11 score values were calculated. For the test module accomplished in the robotic simulator, only one
performance score was available. Mean score values between the groups were compared.
Results: All participant students completed the study. Thirty-two were randomly assigned to training in the robotic platform; and 31,
to the laparoscopic platform. Laparoscopic and robotic groups were not significantly different regarding demographic measures. For
the test task undertaken in the VR laparoscopic simulator, six of eleven mean score results indicated a significant better performance
for the students who trained in the laparoscopic platform. For the test module undertaken in the VR robotic simulator, mean
performance scores were not significantly different between students that practiced in the robotic and in the laparoscopic platform.
Residents predicted greater comfort performing surgical procedures using the platform in which they trained; however, the robotic
training group liked their training more.
Conclusions: Laparoscopic VR simulator training may better teach skills that transfer to other platforms. Training on a robotic
platform did not demonstrate transfer of skills to a laparoscopic platform. Robotic assistance may not teach as generalizable skills, or
may be making the procedure easier, such that skills do not transfer.

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Could Resident Surgeons Safely Perform Laparoscopic

Cholecystectomy for Acute Cholecystitis?

Comparison of Different Simulator Training Methods

in Laparoscopic Colorectal Surgery: A Systematic Review

Masahiro Iseki1, Atsushi Kouyama1, Takeshi Naitoh2, Daisuke

Takeyama1, Akefumi Sato1, Izuru Minemura1, Shigeru Ottomo1,
Masato Oohara1, Kazuaki Hatsugai1, Hirofumi Ichikawa1, Iwao
Kaneda1, 1Department of Surgery, Japanese Red Cross Ishinomaki
Hospital, 2Department of Surgery, Tohoku University Graduate
School of Medicine

Khoshe A Faraj, Anna Donen, Bijendra Patel, Barts and the London
school of Medicine and Dentistry

Background: Our hospital is located at the Ishinomaki area, where the Great East Japan
Earthquake directly hit at 2011. There is no central hospital except our hospital after the
disaster in this area, and we treat many emergency patients including acute cholecystitis. A
lot of resident surgeons belong to our hospital and we put a strong effort to the education for
surgical residents. In our hospital, surgical residents, who have experienced a plenty of
eligible laparoscopic cholecystectomy (LC) for gallstone, are allowed to conduct advanced
LC for acute cholecystitis for educational purposes.
Purpose: The aim of this study was to evaluate the validity of our educational policy
whether surgical residents could manage the LCs for acute cholecystitis.
Method: A total of 61 patients were evaluated retrospectively, who received LC for acute
cholecystitis in our hospital between April 2014 and March 2015. According to their
operator, all patients were divided into 2groups: a residents group and an attending group.
All procedures in residents group were carried out under the guidance of the advisory
surgeon. The clinical characteristics and severity of cholecystitis were assessed as backgrounds of patients. The postoperative outcomes were also analyzed to compare the surgical
qualities of each group.
Result: There was no significant difference about clinical characteristics including gender,
age and comorbidity. White blood cell count (residents group vs. attending group:
132905277 cells/mm3 vs. 130354988 cells/mm3 (P=0.95)), C-reactive protein
(11.411.7 mg/dl vs. 15.214.2 mg/dl (P=0.11)) and Tokyo Guideline 13 severity (Grad1/
2/3: 21/13/4 vs. 9/11/3 (P=0.39)) were not found to be significantly different. The duration
of residents operation was longer than attendings (174.552.5 min vs. 139.438.68 min
(P=0.03)). Blood loss (105.9156.8 g vs. 274.8405.2 g (P=0.10)), rate of conversion to
open surgery (13.2% vs. 13.0% (P=1.00)), postoperative complication (13.2% vs. 17.4%
(P=0.48)) and postoperative hospital stay (5.43.4 days vs. 6.86.4 days (P=0.75)) didnt
show significant differences.
Discussion: Comparing 2groups, there was no significant difference about preoperative
characteristics and severity of cholecytitis. Our results indicated that the safety and therapeutic effect of each group were nearly equal except the duration of operation.
Conclusion: Although it was necessary to be guided by advisory surgeons, residents could
safely perform LC for acute cholecystitis and these experiences might be beneficial to
acquire laparoscopic surgery technique.

Background: The spread of surgical simulation in the last decade and its role for training
outside operating theatres has had many positive impacts on surgical outcomes, especially
in the field of laparoscopy. However, the effects of individual training models have not yet
been explored in detail, particularly for Laparoscopic Colorectal Surgery (LCS). The aim of
this systematic review is to compare the effect of different simulators in training for LCS.
Methodology: Two reviewers conducted this systematic review separately, through
extensive search in databases such as PubMed, Embase, Ovid, Web of Science and Google
Scholar. The key words used were (training OR learning) AND simulator AND
laparoscopic AND colorectal AND surgery. Additional studies were obtained
through manual searching of the reference lists of the retrieved studies and related articles
section. The validated Preferred Reporting in Systematic Reviews and Meta-Analyses
(PRISMA) method was used to report search results.
Results: Twelve original articles were included in this systematic review. These studies
were heterogeneous in various aspects: type of the studies, the experience level of participants and nature of the training sessions. Virtual Reality (VR) and Augmented Virtual
Reality (AVR) simulators reported significant results regarding technical skills when used
alone and compared to cadaver models. However, overall satisfaction rate with cadavers as
a training model was higher when compared to VR and AVR. While there was neutral
satisfaction rate between cadaver and animal model, no studies were found assessing
technical skills after training on animal models.
Conclusion: This systematic review demonstrated that no single simulator training model
was superior in laparoscopic colorectal surgery. However, it has emphasized the role of
AVR for teaching advanced technical skills. There is a need for more comparative studies
and randomized trials in the future; comparing all simulator training models in similar
training settings, involving participants of the same prior experience level.
Keywords: laparoscopy, colorectal, surgery, simulator, training

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Usefulness of Telementoring System to Develop Laparoscopic

Surgery in Rural Hospital

Suggestion of Novel Measurement Methodology for Performance

Evaluation of Medical Equipment

Satoru Imura1, Takuya Tokunaga, MD1, Masayuki Sumitomo1,

Shinichiro Yamada2, Chie Takasu2, Yu Saito2, Jun Higashijima2,
Kozo Yoshikawa2, Tetsuya Ikemoto2, Yuji Morine2, Mitsuo
Shimada2, 1Department of Minimum invasive and Telesurgery,
Tokushima University Hospital, 2Department of Surgery, Tokushima
University

Munenori Uemura, PhD1, Makoto Yamashita1, Morimasa Tomikawa,

MD, PhD, FACS1, Satoshi Obata, MD1, Takahiro Jimbo, MD1,
Noriyuki Matsuoka2, Makoto Hashizume, MD, PhD, FACS1, Yoichi
Nakanishi, MD, PhD1, 1Kyushu University, 2Kyoto Kagaku Co., Ltd

Introduction: We set up a local surgical care department aiming at cancellation short of local surgeons in Tokushima in 2010. After that we tried to standardize operative
procedures in laparoscopic surgery and introduced Telementoring systems (TeMS) between university hospital and our hospital in the rural area with a few cases. To
evaluate the usefulness of live surgery with remote instruction by certified surgeons using TeMS for surgeons in prefectural Miyoshi Hospital 100km away from the
university hospital.
Methods: [1] Laparoscopy assisted gastrectomy (LAG): Miyoshi Hospital (A): 15 cases and Tokushima university hospital (B): 197 cases. Laparoscopy assisted
colectomy (LAC): A: 13 cases and B: 163 cases. We compared the surgical results between the two hospitals. [2] Questionnaire survey about a utility of TeMS was
performed to young surgeons and medical students.
Results: [1] There was not significant difference in intraoperative blood loss (A: 92ml vs. B: 95ml), the lymphnode dissection number (A: 26 vs. B: 28), operative time
(A: 342 min vs. B: 310 min) in LAG. There was not significant difference in intraoperative blood loss (A: 38ml vs. B: 47ml), operative time (A: 264 min vs. B: 220 min)
in LAC. Regarding postoperative complications, there was no difference between the two. [2] Resident, medical students of approximately 70% obtained an answer
saying TeMS is useful in improvement of the regional medicine, They want to work at rural hospital if introduced TeMS.
Conclusion: TeMS could eliminate disparities in laparoscopic surgery between university hospital and rural hospital and contribute education, which leads to findings of
human resources.

Purpose: Three-dimensional (3D) visualization has been shown to improve surgical performance. The effectiveness of 3D endoscopy has previously been measured by
conventional criteria such as the path lengths of the operative instruments, the number of loose or inaccurately placed sutures among other skill-based errors. However,
the quality of suture task performance, i.e., the effectiveness of the suture itself, has never been evaluated using 3D vision. This study uses our newly developed
alternative and more clinically applicable method of suture task performance analysis (Fig. 1). The system evaluates performance quality using pressure-measuring and
image-processing devices in combination with an artificial intestinal model. By measuring four criteria that define an effective suture as well as suture task completion
time, the efficacy of 3D vision can be evaluated and compared with conventional laparoscopy (Fig. 2).
The purpose of this study was to suggest a novel measurement methodology of performance evaluation of medical equipment using a new computerized objective
assessment system.
Methods and Procedures: The participants were 32 medical students who had no experience in performing laparoscopic surgeries. They had taken enough training over
2 weeks to complete the task. The participants were divided into four groups, and performed the mimic intestinal suturing task with our developed simulator under twodimensional (2D) and 3D endoscope conditions. Group A performed the task with 2D first, then with 3D; Group B performed the task with 3D first, then with 2D; Group
C performed the task with 2D first, then with 2D; and Group D performed the task with 3D first, then with 3D.
The performance scores of each group in both conditions were then compared.
Results: There were significant differences between 2D and 3D in volume of air pressure leak (12.43 9.16 kPa and 22.62 11.07 kPa, respectively), number of fullthickness sutures (2.00 0.87 pairs and 2.88 0.33 pairs), suture tension (53.19 16.52 % and 63.56 10.63 %), and operation time (1170.25 242.75 s and 840.00
151.60 s) (Fig. 3a). There were no significant differences between the first and second trial in the same condition (Groups C and D) (Fig. 3b).
Conclusions: The usefulness of the 3D endoscope was evaluated objectively and quantitatively using the objective skill assessment system.
3D endoscope might be superior to 2D endoscope for performing laparoscopic surgeries intuitively.
Our proposed suggestion would be an effective way to evaluate the performance of medical equipment.

Fig. 1 .

Fig. 2 .

Fig. 3 .

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Comparison of the Learning Curves of a Suturing Device

and Standard Laparoscopy

Surgical Simulation Got You Stressed? Role of Skin Conductance

as a Stress Indicator in Surgical Education

Steven Leeds, MD2, Lizzy Wooley, BBA, EMT1, Ganesh

Sankaranarayanan, PhD1, James Fleshman, MD, FACS, FACRS2,
Sanket Chauhan, MD1, 2Baylor University Medical Center, 1Center
for Evidence Based Simulation, Baylor Scott and White Health

Monali Mohan, MBBS, Denny Yu, PhD, Becca L Gas, MS, EeeLN H
Buckarma, MD, Amro M Abdelrahman, MBBS, Susan Hallbeck,
PhD, David R Farley, MD, Mayo Clinic

Introduction: Endo360TM (EndoEvolution, LLC; Raynham, MA) is a suturing device aimed to decrease the long learning curve
associated with conventional laparoscopic suturing and knot tying. The aim of this study is to compare the learning curves between
conventional laparoscopy and Endo360TM .
Materials and Methods: In this prospective single blinded non-randomized controlled crossover study, we recruited 20 general
surgery residents ranging from beginner (PGY12, n=12) to competent (PGY35, n=8). They were assigned to perform laparoscopic
knot tying and suturing tasks using either Endo 360 or Laparoscopic needle holders (in no particular order) before crossing over to
the other device. The proficiency standards were developed by collecting the data for Task Completion Time (TCT in sec), Dots on
Target (DoT in n) and total Deviation (D in mm) on 5 expert attending MIS surgeons (Mean 2SD). The test subjects were
proficient when they reached these standards 2 consecutive times.
The task consisted of applying a standard square knot at one end on a physical model based 5 cm incision followed by passing
running sutures through pre-marked dots (5 mm apart) on each side of incision. T tests and generalized linear model analysis
(GLMA) were performed.
Results: On matched pair t-test of beginner group, significant difference was observed between mean numbers of attempts to reach
proficiency for Lap vs Endo360 (p=0.0027). This difference was not statistically significant in competent group. On t-test, there was
significant difference for number of attempts to attain proficiency between both Endo 360 (p=0.0126) and Lap (p\0.0001)
The GLMA for TCT demonstrated significantly less time for Endo360 vs Lap task (p\0.0001), beginner vs competent (p=0.0003)
and increasing number of trials (p=0.0005). There were significantly less DoT for Endo360 as compared to Laparoscopy (p\0.0001).
Similarly, analysis on the D demonstrated a significant deviation in Endo 360 compared to laparoscopy (p\0.0001). However, no
significant difference was observed between both beginners and competent or increasing number of trials for both DoT and D.
Conclusions: The learning curve for Endo 360 is shorter than standard laparoscopy for beginners, but not for more advanced
surgeons. It is consistently associated with significantly less time for suturing and knot tying for surgeons across varied level of skill
set. This comes at the expense of accuracy with standard laparoscopy associated with more dots on target and less total deviation
from targets. However, the validity of such metrics in clinical environment remains to be validated.

Background: Safe surgical practice requires a combination of technical and cognitive abilities. Both sets of skills can be impaired
by intra-operative stress, compromising performance and patient safety. One of the ways to safely document and evaluate stress is to
measure it in a simulated setting. We sought to observe the effect of stress on surgical interns while performing surgical simulation
skills
Methods: This study was conducted alongside an objective assessment (Surgical Olympics) event which consisted of 11 stations:
suturing, open knot tying, written test, imaging test, laparoscopic PEG transfer etc. Sixteen first-year residents with \1 month
experience wore skin conductance monitors on their forearm. Stress was recorded by these monitors continuously throughout the
event and averaged for every station. The most/least stressful stations were defined as number of residents who had the highest/
lowest plus second highest/lowest stress levels respectively while performing on that particular station.
Results: Among 16 interns, 6 had the highest stress levels for the video commentary station and 6 had highest stress levels for the
PEG transfer station. Interestingly, laparoscopic knot tying station was the only station at which no intern was maximally stressed.
Seven interns found the imaging station least stressful and 4 interns were least stressed at the written test station, lap knot tying and
fascial closure (1 X 1 cm) station.
Conclusions: Video commentary, where participants looked at a short video of a surgical procedure and answered goal directed
questions, was the most stressful station. While directed questions are stressful, interns may have felt more comfortable at other
stations where they had a good idea of what to expect (obvious by names). The laparoscopic PEG transfer station tests a skill which
is rarely practiced as a medical student and hence the interns felt higher stress levels. The lower stress levels for imaging and written
tests might be explained by the fact that they are knowledge based stations only and do not require a skill set. Surgeons are subject to
many intra-operative stressors that can impair their performance; more insight into the relationship of stress and performance is a
critical factor for the quality of health care.

P175
Characteristics of Learning Curve in Minimally-Invasive Ileal
Pouch Anal Anastomosis in a Single Institution
Ahmet Rencuzogullari, MD, Luca Stocchi, MD, Meagan Costedio,
MD, Emre Gorgun, MD, Hermann Kessler, MD, Feza H. Remzi, MD,
Department of Colorectal Surgery, Digestive Disease Institute,
Cleveland Clinic
Introduction: Previous work from our institution has characterized the learning curve for open ileal pouch-anal anastomosis
(IPAA). The purpose of the present study was to assess the learning curve of minimally-invasive IPAA.
Methods and Procedures: Learning curves on 372 cases of minimally-invasive IPAA by 20 surgeons (10 seniors vs. 10 juniors)
during 20022013, included in an institutional, prospectively maintained database were assessed for pelvis sepsis,other pouchrelated complications (hemorrhage, anastomotic stricture or separation, pouch failure, fistula), operative times and conversion rates.
Predicted outcome models were constructed using perioperative variables selected by stepwise logistic regression, using Akaikes
information criteria. Cumulative sums (CUSUM) of differences between observed and predicted outcomes were graphed over time
to identity possible patterns demonstrating improvements for the institution, senior vs junior surgeons and busiest individual
surgeons (surgeon A, 71 cases, and surgeon B, 54 cases)
Results: Institutional outcomes significantly improved for pelvis sepsis rate (18.2% vs. 7.0%. CUSUM peak after 143 cases,
p=0.001, Fig. 1A) and other pouch-related complication rates (32.9% vs. 12.4%, CUSUM peak after 155 cases, respectively,
p\0.001, Fig. 2A). Institutional total proctocolectomy mean operative times significantly decreased (307 min vs. 253 min, CUSUM
peak after 84 cases, p\0.001), unlike completion proctectomy (p=0.093) or conversion rates (10% vs. 5.4%, p=0.235). Similar
learning curves were identified among senior surgeons but not among junior surgeons (Figs. 1B, C, 2B, C). Learning curves were
identified for both the 2 busiest individual surgeons for pelvic sepsis (peaks at 47 and 9 cases, p=0.045 and p=0.002), and other
pouch complications (peak at 41 cases for both, p=0.002 and p=0.006), but only in one surgeon for operative times (CUSUM peak
after 13 cases for both total proctocolectomy and completion proctectomy (p=0.002 and p=0.006) (Table)
Conclusion: Pouch complications are the most consistent and relevant learning curve endpoints in laparoscopic IPAA.

P177
Validation of the Novel Inverted Peg Transfer (IPT) Task:
Advancing Beyond Regular Peg Transfer (RPT) Task for Surgical
Simulation-Based Assessment and Training
Amro M Abdelrahman, MD, Denny Yu, PhD, Bethany R Lowndes,
EeeLN H Buckarma, MD, Becca L Gas, David R Farley, MD, M.
Susan Hallbeck, PhD, Juliane Bingener-Casey, MD, Mayo clinic
Introduction: The study goal was to validate an inverted Peg Transfer (iPT) task for surgical training assessment using Messicks
validation model. Although regular Peg Transfer (rPT) is used to assess basic laparoscopic surgery skills, rPT doesnt expose
surgical trainees to all required intra-abdominal laparoscopic situations (i.e. intra-abdominal wall during laparoscopic ventral hernia
repair (LVHR)).
Methods and Procedures: A crossover-randomized design was used to compare participants performance during rPT and iPT in a
medical simulation center. The iPT consisted of a magnetic pegboard with standard rPT pegs and triangles attached to the ceiling of
a Park Trainer Box on a laparoscopic-video tower (Stryker Corp.). iPT, like rPT, is designed to assess hand-eye coordination,
ambidexterity, and depth perception plus assesses skills needed to place mobile objects against gravity like for LVHR (content
evidence). Participants were divided into two groups: novices (medical students and first-year surgical residents without laparoscopic experience), and experts (Minimally Invasive Surgery (MIS) attendings). Participants were asked to complete each version of
peg transfer separately (6-minutes maximum). rPT was completed on a Fundamentals of Laparoscopic Surgery trainer. This was the
first exposure to iPT for both novices and experts. Completion time (efficiency) and number of dropped and transferred triangles
(precision) were collected. A scoring rubric was used to calculate a normalized participant score between 0 and 100, where a higher
score indicated better performance (internal structure validity). Wilcoxon rank sum and Mann-Whitney tests were performed as
appropriate using SPSS v22 (IBM Corp.) with a=0.05. Receiver-Operating-Characteristic Curves were graphed for the two task
scores to measure the Area Under the Curve (AUC) to identify tasks sensitivity and specificity in differentiating between novices
and experts.
Results: Thirty-six novices and nine experts participated. Both experts and novices had significantly longer completion time and
lower scores during iPT than rPT (Table 1). Within iPT, novices averaged 158 seconds longer (p=0.047), and 36-point lower scores
than experts (p\0.01). However, there were no statistically significant differences between novices and experts in either completion
time (117 sec novices, 187 sec experts, p=0.24) nor scores (novices=73, experts=81, p=0.12) for rPT. The iPT scores had a higher
AUC than the rPT (iPT= 0.92; rPT= 0.67).
Conclusion: IPT is a valid method of assessing surgical trainees and has higher specificity and sensitivity than rPT for differentiating between novices and experts. As advanced MIS becomes more common, it is important that iPT be included in surgical
simulation-based training and assessment curriculums.

Fig. 1 .
Table 1 .

Fig. 2 .

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P178

P180

Analysis of Medical Accidents in Laparoscopic Surgery

by the PM-Shell Model: A Feasibility Study

Safety and Effectiveness of Telementoring in Surgery:

A Systematic Review

Kazuhiko Shinohara, MD, PhD, Tokyo University of Technology

Elif Bilgic1, Sena Turkdogan1, Amin Madani1, Yusuke Watanabe2,

Tara Landry3, Melina C Vassiliou1, 1Steinberg-Bernstein Centre
for Minimally Invasive Surgery, McGill University Health Centre,
2
Hokkaido University Graduate School of Medicine, 3Montreal
General Hospital Medical Library, McGill University Health Centre

Background and Objective: Analysis of medical accidents in surgery is essential for preventing similar mishaps. The SHELL
model, which was created by Hawkins, has been widely used to analyze aviation and industrial accidents according to five
contributing factors: Software (S), Hardware (H), Environment (E), and Liveware (person directly [L1] and indirectly [L2] concerned). Here we propose the Pm-SHELL model, an extension of the SHELL model to incorporate patient factors (P) and
organizational management factors (m). The feasibility and effectiveness of the Pm-SHELL model for analyzing medical accidents
in laparoscopic surgery are investigated in this study.
Material and Methods: Twenty-one cases of accidents in laparoscopic surgery in Japan that have been described in the official
incident reports are analyzed by the Pm-SHELL model. Each case is analyzed according to seven contributing factors: S, H, E, L1,
L2, P, and m. The contribution of each factor is scored on a five-point scale (1, minimal contribution; 5, maximal contribution).
Results: The scores (mean standard deviation for the seven contributing factors are as follows: P, 2.860.77; m, 4.480.91; S,
3.140.46; H, 2.861.24; E, 3.810.50; L1, 4.520.85; L2, 4.240.85. Human factors (L1, L2) and organizational management
factors (m) are found to be the main contributing factors of medical accidents in laparoscopic surgery.
Conclusion: The Pm-SHELL model is a feasible and useful tool for quantitatively analyzing medical accidents in laparoscopic
surgery and provides an intuitive understanding of multiple contributing factors.

P179
Are Practicing Surgeons Using the Most Effective Training
Methods When Learning New Procedures and Technologies?
Steven J Hasday, BS, Todd A Jaffe, BBA, Meghan C Knol, MS, Jason
C Pradarelli, MS, Justin B Dimick, MD, MPH, University
of Michigan Medical School
Introduction: New procedures and technologies are continuously introduced into practice across a variety of surgical fields.
Learning curves among surgeons in practice may be steep, leading to avoidable harm during the diffusion process. There is very
little information about how practicing surgeons learn new things. Our aim is to understand how practicing surgeons utilize available
training methods to learn new procedures and technologies, which methods are perceived as most effective, and to determine
barriers to using the most effective methods.
Methods and Procedures: We designed a 22-question survey to evaluate how practicing surgeons use available training methods
when learning new procedures/technologies, as well as the perceived efficacy of those methods. Invitations to participate were sent
via email to 77 faculty surgeons at a large Midwestern academic health center. Respondents were asked which of five common
learning methods they used most commonly, and which they believed to be most effective. Those with discordant responses
were prompted to indicate how important various barriers are in accounting for this discrepancy (5-point Likert scale: 1=Not At All
Important; 5=Very Important). The survey was administered online using Qualtrics Survey Software. Proportions in each
response category were compared using chi-square tests.
Results: The survey response rate was 71% (55/77). Surgeons reported commonly using self-directed study such as videos and
textbooks (29%) and didactic short courses (20%) to learn new procedures or technologies. Much fewer surgeons reported using
proctoring (10%) or mini-fellowships (0%). However, when asked which training methods were likely to be the most effective for
safely implementing new procedures or technologies in their practice, 49% selected the most rigorous approaches (i.e., proctoring or
a mini-fellowship). Only 13% of surgeons identified self-directed study or didactic short courses as the most effective methods.
Surgeons reported that the greatest barriers to using what they perceived as the most effective training method were that it would
require too much time (mean = 3.63) and be prohibitively expensive (3.21). Surgeons also reported that they have confidence
[they] can implement safely using a less rigorous training method (3.32).
Conclusions: Our results indicate that among surgeons there is a marked disconnect between the most commonly used training
methods and those deemed most effective. Addressing the reasons for this discrepancy could improve diffusion of new procedures
and technologies in to practices, reducing the learning curve and improving patient outcomes.

123

Background: Dissemination of advanced technologies and surgical procedures relies on successful mentoring relationships. While
this model works well for formal training programs, it is not feasible for surgeons who want to integrate new procedures into their
practice, and who may be geographically distant from appropriate mentors. To bridge this gap, telementoring has emerged as an
alternative to on-site mentoring. The purpose of this systematic review was to evaluate the quality of the evidence supporting the use
of telementoring for surgical procedures.
Methods: A systematic literature search of bibliographic databases, and conference proceedings was performed up to March 2015.
Studies were included if they reported on the use of a platform to communicate between surgeons during a clinical encounter.
Studies reporting only encounters between surgeons and patients, non-clinical telementoring or for the purposes of assessment were
excluded. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality.
Results: Preliminary results identified 19,762 studies. After screening, 43 were included totalling 959 telementored cases (median 6
[320] cases/study). Study characteristics can be seen in Fig. 1. Most studies had strong methodological limitations: 32(74%) studies
had no comparative group and 30(70%) described their findings without any statistical analysis. Eleven(26%) studies were comparative but none of them were randomized trials. The majority reported no added risk of intra-operative complications, and for the
comparative studies, operative times were similar to non-telementored cases. Ten(23%) studies reported system failures that
included set-up difficulties and loss of internet connection during telementoring. All included user-reported outcomes with high
mentor/mentee satisfaction and 2(5%) reported assessments of mentee performance. Two(5%) studies mentioned the importance of
mentor-mentee relationships, but none assessed the impact of longitudinal relationships between mentor and mentee. None of the
studies mentioned the costs of implementating the telementoring program beyond the cost of the equipment.
Conclusion: The quality of the current evidence is limited, but telementoring is associated with a low risk of complications and high
user satisfaction. There is a need, however, for large scale, comparative studies that provide evidence for the effectiveness of
telementoring. There is also a need to evaluate platforms, cost, and the role of the mentor-mentee relationship.

Fig. 1 Characteristics of 43 studies

P181
Design of an Inexpensive Physical Endoscopic Simulator
to Facilitate Teaching the Fundamentals of Endoscopic Surgery
Skills
Neil King, MD, Anastasia Kunac, MD, FACS, Gregory J Gallina,
MD, FASCRS, Erik Johnsen, BS, Aziz Merchant, MD, FACS,
Rutgers- The State University of New Jersey (All Campuses)
Background: Surgical simulation allows skills acquisition, shortens learning time for technical procedures, and may reduce patient
complications. Colonoscopy is a technical skill mandated by ABS of surgeons and endoscopy training is well suited to a simulation
environment. Virtual reality endoscopy systems which have been adopted for national level testing and training are cost-prohibitive
for many training programs. We therefore sought to develop an inexpensive physical endoscopic simulator to facilitate Fundamentals of Endoscopic Surgery (FES) skills training. We hypothesized that we could build a feasible model for teaching basic
colonoscopic skills for less than $500.00.
Methods: We constructed a physical colonoscopy simulator from locally available commercial materials. Data on construction
times, material cost, and materials used were captured. We then tested the feasibility of the model with respect to the performance of
the five Fundamentals of Endoscopic Surgery tasks by surgical residents and attending physicians. Participants were given an
orientation to the five FES tasks before attempting the simulator. Participants were given two attempts to complete the five tasks.
Data were collected on time to completion of the colonoscopy, loop reduction, and polyp snare, as well as demographic data.
Participants also filled out a survey after using the simulator to assess the realism of the model. .
Results: The initial physical simulator was built at a cost of $73, and took approximately 2.5 months to effectively troubleshoot and
construct. The model measures 30x36 and weighs 8.5 pounds. and with appropriate instructions and materials can be built in less
than 90 minutes. We are able to simulate the five skills tested on the FES practical exam on our model. Our feasibility study has
enrolled 15 participants: 100% of participants were able to complete all five tasks with a mean time to completion of simulated
colonoscopy of 8:24 min [SD 2:36min] . Participants ranked the ease of performing the five tasks using our model and found the
loop reduction and the retroflexion tasks the most difficult.
Conclusion: We have developed and constructed a low cost colonoscopy simulator. We have demonstrated that the five described
FES skills can be performed on our simulator by both expert and novice endoscopists. Given that the simulator is inexpensive and
easily reproducible, we believe our simulator can be be used as a cost effective method to teach basic endoscopic skills in other
surgical residency training programs.

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P182

P184

Anxious About Surgical Residency Performance? Are You

and Your Hands Ready?

Intestinal Stoma Prolapse and Surgical Treatments of This

Condition in Children

EeeLN H Buckarma, MD, Denny Yu, PhD, Becca Gas, MS, David
Farley, MD, Susan Hallbeck, PhD, Mayo Clinic

Prince Johnson, Student, MD, Facullty of medicine university of Oslo

Introduction: Currently there is no definitive method of determining if a surgical candidate

for residency is a good match when it comes to dexterity. We sought to observe if a self
answered performance anxiety questionnaire could show any relationship between anxiety
and performance on FLS peg transfer for surgical interns.
Methods: Forty-three residents were asked to perform the FLS peg transfer. During the task
the total time, with penalties of 15 seconds added for each peg dropped out of the field, was
recorded. Residents completed a validated anxiety survey that was adapted to surgical tasks.
On a 4-point scale (1= not at all, 2= sometimes, 3= often, 4= very often) residents rated the
frequency with which they experienced the 15 anxiety related symptoms. These 15
symptoms were then categorized into 20 point somatic, worry and concentration subcategories; total anxiety was calculated by the sum of these three sub-scores. A correlation
analyses was conducted on SPSS (v22) to investigate the relationship between FLS times
and the 20-point anxiety categories (worry, somatic, and concentration).
Results: Total anxiety was not associated with performance time. But on the analyses of
anxiety subcategories, we found a positive association between worry scores and performance times (q=0.32, p\0.05) and a negative association between concentration scores and
performance times (q=-0.36, p\0.05).
Conclusion: Our preliminary data illustrates higher worry anxiety correlated with slower
performance in the FLS peg transfer while higher concentration anxiety improved performance for the surgical interns at our institution. Further studies are needed to see if anxiety
questionnaire scores can actually predict technical skill performance in the operating room.

P183
A Window into the Mind: Preliminary Steps Towards
the Development of a Hernia Management Assessment Tool
for Surgeons
Mohammed AlRowais, MD, Amin Madani, MD, Yusuke Watanabe,
MD, PhD, Mohammed Al Mahroos, MD, FRCSC, Elif Bilgic, Melina
Vassiliou, MD, MEd, FRCSC, FACS, Steinberg-Bernstein Centre
for Minimally Invasive Surgery and Innovation, McGill University
Health Centre, Montreal, Canada
Introduction: Expert surgeons organize knowledge into mental representations they draw
from when caring for patients. The richness of this network is what defines expertise, and
the complex integration of knowledge and skills is difficult to assess. Inguinal hernias are
common surgical problems, however, there are still gaps in the management of patients
with hernias that could be addressed though education. The purpose of this qualitative study
was to explore the use of a clinical vignette, open-ended questions and videos as probes for
uncovering expertise in the management of patients with inguinal hernias, and as an
eventual methodology for the development of assessments.
Methods: This was a qualitative study using semi-structured interviews based on a patient
with an inguinal hernia including two short video clips of a laparoscopic TEP repair. The
questions initially centered around management of the patient, and then participants were
asked to comment about the videos, including recommendations they might have for the
surgeon. Participants included two attending surgeons who perform hernia surgery, and
nine surgical residents (two-PGY1, two-PGY2, one-PGY3, two-PGY4, two-PGY5). All
interviews were video-recorded and transcribed.
Results: Surgeons used language that was very specific, focused and practical. They were
quickly oriented to the operative field, identified anatomical planes and were concrete in
their recommendations. They demonstrated evidence of a robust cognitive structure also
rich in readily accessible content. Senior residents used technical language that seemed
directly out of a textbook. They were less oriented to the surgical field and when describing
the technical aspects of the procedure, they used vague terms and general principles. As a
group they had a structured approach to the patient with clear gaps in content. Junior
residents tended to focus more on the history, and detailed physical exam including surgical
risks. They were not able to orient to the procedure or make any suggestions, and their
comments were focused mostly on safety. They seemed to have an incomplete cognitive
structure in addition to content lacunes.
Conclusion: This study identified clear differences in cognitive schemas for the management of inguinal hernias among surgeons. This methodology may be used to create
assessments of mental representations using expert patterns related to language, focus and
the ability to orient to video clips. These data may also provide insight into how surgeons
acquire expertise at various stages of training and could be used to provide feedback to
trainees or as part of the surgical curriculum.

Background: An intestinal stoma is a surgical opening of the intestine, mostly sutured to

the anterior abdominal wall. It is a common lifesaving operative procedure done on children. Stoma prolapse is one of the common complications of stoma. A significant number
of stoma prolapse patients require surgical correction.
Aim: This thesis is in two parts. The first part is a literature review of intestinal stoma
prolapse and its surgical treatments. The second part is an evaluation of the effect of
surgical treatments of this condition on children at OUS-R.
Methods: Literature-A literature search using the PubMed and Google scholar database was
performed. Studies included randomized clinical trials, observational studies, letters, editorials and
review articles. Sixty-three English-language studies were selected for the literature review.
Patients Evaluation: Design, Setting, and Participants - A retrospective review of pediatric patients
(\13 years) surgically treated for intestinal stoma prolapse at OUS-R from 2001 to 2013.
Results: Literature-Most published incidence of intestinal stoma prolapse for children
varies from 8.1% to 25.6%, median 18.8%. Many proposed surgical repair procedures for
stoma prolapse are available; and varies from being ineffective to 100% effective.
Results: Patients evaluation at OUS-R-From 2001 to 2013, 14 of the 304 children with
stoma (4.6%), experienced stoma prolapse. Five of these 14 stomas were considered
appropriate for closure, and 9 stoma prolapse were surgically corrected: Five of the 9
patients with stoma prolapse were initially diagnosed with Mb Hirschsprung. Median age at
stoma formation for the 9 patients was 1.7 years. Surgical procedures and success rate:
Median 2, range 19 operations/person; varies from being ineffective to 50% effective.
Conclusion: Findings from the literature review and the study at OUS-R suggest that,
stoma prolapse repair is a surgical challenge. Thus, preferably when possible, closure of the
stoma would be most suitable. Neither the extra-abdominal nor the intra-abdominal surgical
methods have been proven superior to one another (in large studies). More research and
larger potential studies would be required. An intra-abdominal surgical procedure which
best addresses intestinal fixation, may be the best surgical repair method for sliding stoma
prolapse. Incidence of stoma prolapse in our series of pediatric patients at OUS-R is lower
than most (if not all) published incidence in the pediatric medical literature.

P185
Intraoperative Management of Mirizzi Syndrome
with Cholecystohepaticodochal Fistula: A Case Report
Christopher F McNicoll, MD, MPH, MS1, Raffi A Kotoyan, MD1,
Lindsay M Wenger, MD1, Cory G Richardson, MD1, Charles R St.
Hill, MD, MSc, FACS1, Matthew S Johnson, MD2, Nathan I Ozobia,
MD, FACS3, 1Department of Surgery, University of Nevada School
of Medicine, 2Desert Surgical Associates, Las Vegas, Nevada,
3
University Medical Center of Southern Nevada
Pablo L. Mirizzi described in 1948 the eponymous syndrome of obstructive jaundice caused
by a gallstone compressing the common hepatic duct. Cholecystobiliary and bilioenteric
fistulae are complications of Mirizzi syndrome, as further classified by McSherry and
Csendes in 1982 and 1989, respectively. Mirizzi syndrome affects 0.7% to 1.1% of patients
undergoing cholecystectomy, though fistulae are less common. Unusual biliary anatomic
variants in 25% to 43% of patients complicate the diagnosis, though cholangiography or
endoscopic retrograde cholangiopancreatography (ERCP) by the surgeon is beneficial. We
describe the management of a cholecystohepaticodochal fistula secondary to Mirizzi Syndrome, involving a biliary anatomical variant.
This 59 year old male presented to the emergency department with one month of intermittent right upper quadrant pain, nausea, vomiting, dark colored urine, acholic stool, 15
pound weight loss, scleral icterus, and jaundice. His abdomen was soft, nondistended,
without Murphy sign, but with mild tenderness in the right upper quadrant and hepatomegaly. One month prior, he was treated non-operatively for cholecystitis at an outside
hospital with ciprofloxacin and metronidazole. Abdominal ultrasound revealed gallstones, 6
millimeter gallbladder wall, dilated intrahepatic ducts, 1.9 centimeter common hepatic duct
with possible hepaticodocholithiasis, and no choledocholithiasis or pericholecystic fluid.
Laboratory evaluation revealed total bilirubin 8.5 mg/dL, alkaline phosphatase 722 U/L,
AST 212 U/L, ALT 225 U/L, no leukocytosis, INR 1.0, and urine bilirubin 4+. On hospital
day 3, a gastroenterologist performed an ERCP with stent placement and sphincterotomy,
reporting a large proximal common bile duct stone that could not be removed. On hospital
day 5, a laparoscopic converted to open cholecystectomy was performed after difficulty in
obtaining the critical view of safety given extensive adhesions. A fistula was identified
between the infundibulum and the right posterior sectoral duct, eroding one-third of the duct
wall and obliterating the cystic duct. Multiple stones, but no stent, were observed in the
operative field. Cholangiography confirmed the stent from the common bile duct to the right
anterior sectoral duct, signifying a variant found in 2% to 4% of patients. The hepaticodochotomy was closed primarily with a T-tube, removed 12 weeks later in the office, and
he is asymptomatic. An ERCP will remove the stent and any residual stones.
The delay in recognizing this complicated Mirizzi syndrome in a biliary tract variant could have
been averted if adequate ERCP images were obtained pre-operatively. This would have better
informed the subsequent surgical approach, with potential savings in operative time.

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P186

P188

Ultrasound Is Not a Reliable Modality for Diagnosing

Cholecystosis

Acute Calcular Cholecystitis in Diabetic Patients: A Ten-Year

Experience in a Tertiary Center

Sharique Nazir, MD1, Alex Bulanov, MS, DO2, Anastasiya

Nelyubina, BS3, Ishtiaque Aziz, BS3, Jordan K Magruder, BS3, 1NYU
Lutheran Medical Center, 2NYIT College of Osteopathic Medicine,
3
St. Georges University

Abdel Rahman Abdel Aal, Consultant, Gaby Jabbour, Resident,

Wanis Ibrahim, Consultant, Ibnouf Suleiman, Fellow, Zia Aftab,
Consultant, Ayman Ahmed, Consultant, Hamad Medical Corporation

Introduction: The primary workup for right upper quadrant pain in the context of fever, nausea, vomiting,
and leukocytosis is biliary ultrasound. Ultrasonography is a reliable diagnostic modality for cholelithiasis,
but has a high false negative rate for acute cholecystitis, especially in diabetics and the elderly. Our goal was
to investigate whether a negative biliary ultrasound unnecessarily delays surgery in the context of a clinical
picture that is highly suggestive of cholecystitis.
Methods: We conducted a retrospective chart review of all laparoscopic cholecystectomies performed by
three experienced minimally invasive surgeons at our 500-bed urban community teaching hospital, between
2011 and 2015. We included all cases with biliary ultrasounds negative for cholecystitis. Ultrasound reports
were scored for the cardinal sonographic findings of acute cholecystitis: impacted stone in cystic duct or
gallbladder neck, positive sonographic Murphys sign, thickened gallbladder wall ([3mm), distention of
gallbladder lumen ([ 4cm transverse and [9cm longitudinal), and pericholecystic fluid. The ultrasound
report was then compared to the description of the gallbladder in the operative note and the final pathologic
report. Additional data collected involved the initial clinical presentation, labs, additional preoperative
imaging, time from clinical presentation to operation, length of hospital stay, and resolution of pain on postoperative follow-up.
Results: Of the 453 laparoscopic cholecystectomies performed, 223 had ultrasounds negative for cholecystitis. In the negative ultrasound group the average cholecystitis ultrasound score was 0.78 and all but 31
of the ultrasounds showed gallstones. Subsequent preoperative workup included 8 HIDA scans, 64 MRCP,
63 CT scans. All cases mentioned gallbladder inflammation in the operative report. On pathology, 177
showed chronic cholecystitis, 22 showed combined chronic and acute cholecystosis, 16 showed necrotic/
hemorrhagic cholecystitis, 19 showed mucosal ulceration, 4 with tubular adenoma, 4 with intestinal
metaplasia and one each showed acute cholecystitis, porcelain gallbladder, antral metaplasia, low-grade
dysplasia, and gallbladder adenocarcinoma. Average time from presentation to surgery was 1.1 days and
length of stay was 1.7 days.
Conclusion: A negative billary ultrasound can confuse the picture of right upper quadrant pain. Most cases
turned out to be chronic cholecystitis that could be managed electively; however, there was a 9% rate of
necrotic cholecystitis, a true surgical emergency. Many studies have shown that early cholecystectomy leads
to shorter length of stay and lower costs; therefore the need for additional workup versus directly proceeding
to surgery must be closely examined.

P187
Laparoscopic Cholecystectomy for Acute Abdomen Due
to Torsion of Gallbladder Successfully Diagnosed Preoperatively
A Single Center Experience
Hidejiro Urakami, MD, PhD, Hiroto Kikuchi, MD, Yuichi Nishihara,
MD, Yoshiki Kawaguchi, MD, Jo Tokuyama, MD, PhD, Koji Osumi,
MD, Shiko Seki, MD, PhD, Atsushi Shimada, MD, Takashi Oishi,
MD, PhD, Yo Isobe, MD, PhD, Sumio Matsumoto, MD, PhD,
National Hospital Organization Tokyo Medical Center
Introduction: Torsion of gallbladder (GT) is a rare entity that brings a diagnostic challenge preoperatively
to both surgeons and radiologists. It is known to occur when there is rotation of the gallbladder along the
axis of the cystic duct and the vascular pedicle. GT typically presents as an acute abdomen requiring
emergency surgery, however, preoperative diagnosis is difficult.
Cases: Five hundred and twenty seven laparoscopic cholecystectomy was done in our hospital since 2009 to
2014. We experienced three cases (0.6%) of GT successfully diagnosed preoperatively during this period.
Case 1 A 88-year-old male visited our hospital for intermittent abdominal pain continuing for one week.
Slight abdominal tenderness and Murphys sign were detected and blood test showed slight elevation of
CRP with no abnormality of liver function tests. MDCT and ultrasound demonstrated a markedly enlarged
gallbladder with a slightly thickened wall and an enhanced twisted cystic pedicle without stones, and
diagnosed GT. In consideration of mild abdominal findings and slow onset, laparoscopic detorsion and
cholecystectomy was done one day after emergency admission. The gallbladder was gangrenous and was
rotated clockwise about 180 degrees at the cystic pedicle. Histological findings revealed massive necrosis
and hemorrhage. Case 2 A 78-year-old female was diagnosed acute cholecystitis due to gallbladder stones
by family doctor and transferred to our hospital. Laboratory findings revealed elevated inflammatory
reactions with normal liver function tests. Diagnosed GT by MDCT and ultrasound, and emergency
laparoscopic cholecystectomy was done by reduced-port surgery. The gallbladder was rotated clockwise
about 540 degrees. Histological findings revealed cholecystitis with hemorrhage. Case 3 A 80-year-old
female was treated conservatively for acute cholecystitis for 20 days at another hospital. The patient visited
our hospital 5 days after discharge from another hospital due to recurrent abdominal pain. Body temperature
was normal and blood test showed slightly elevated liver function tests with normal range of inflammatory
reactions. Diagnosed GT by ultrasound, and emergency laparoscopic cholecystectomy was done. The
gallbladder was gangrenous and was rotated clockwise about 180 degrees. Histological findings revealed
chronic and acute cholecystitis. All the patients recovered without significant complications and discharged
from our hospital 5 to 14 days following surgery.
Conclusion: We could successfully perform emergency laparoscopic cholecystectomy for all three GT
cases diagnosed preoperatively by MDCT and / or ultrasound, however, some of these cases exhibited
worrisome course preoperatively. Early diagnosis and immediate laparoscopic intervention can help to
achieve a better patient outcome.

123

Introduction: Acute cholecystitis is most commonly caused by cystic duct obstruction from stones (calculous cholecystitis); only 10% of acute cholecystitis is acalcular, developing in absence of stone. Risk
factors for cholecystitis include increasing age, female sex, obesity or rapid weight loss, drugs, and pregnancy. Numerous studies have described increased morbidity and mortality of acute cholecystits in diabetic
patients. Qatar is among the countries with high prevalence of diabetes.
The aim of this study was to determine the rate of complications and surgical oucomes of acute calcular
cholecystits among patients with diabetes mellitus in a country with high prevalenec of diabetes.
Methods: This is a retrospective study of adult diabetic patients, admitted with acute calcular cholecystitis,
at Hamad General Hospital during the period from January 1st, 2004 to December 31st 2013.
Results: During the period from 01/01/2004 to 31/12/2013, a total of 113 diabetic patients were admitted
with acute calcular cholecystitis at Hamad General Hospital. Males and females constituted 57% and 43%
these patients respectively. Mean age at time of presentation was 57 years. Abdominal pain was the most
common presenting symptom (in 97.3% of patients) followed by fever (84.1%). Although abdominal
tenderness was the most common detected clinical sign (in 85.6%), Murphys sign was positive in only
33.3%. Majority of patients were receiving oral medications for diabetes (71%) prior to presentation. About
9.3% of patients were newly discovered to have diabetes on presentation. The average HbA1C at presentation was 7.7%. The most common ultrasonpgraphic findings were distended gallbladder (72%), wall
thickening (71%) and detection of peri-cholecystic fluid (68%). Biliary tree dilation was seen in only 13% of
patients. 40 patients were treated conservatively, and 73 were operated: Laproscopic cholecystectomy was
the most commonly used surgical treatment (70 cases: 96%) with conversion rate of 4% (3 cases). Average
operative time was 98 minutes. Intra-operatively, 3 cases (4.1%) were found to have gall bladder gangrene.
The complications were distributed as follows: 1 case of bowel injury (1.4%), 1 case of wound infection
(1.4%), and 2 cases of abdominal collection (2.7%). No mortality was seen in our series. Average hospital
stay was 3.8 days.
Conclusion: Our study revealed that the rate of complications of acute calcular cholecystitis and its surgery
is relatively lower than what was published in previous reports.

P189
Laparoscopic Versus Open Radical Total Gastrectomy
with Pancreas- and Spleen-Preserving Splenic Hilum Lymph
Nodes Dissection for Proximal Advanced Gastric Cancer
Wei Wang, Wen Jun Xiong, Dechang Diao, Yansheng Zheng, Lijie
Luo, Jin Wan, Guangdong Province Hospital of Chinese Medicine,
the Second Affiliated Hospital of Guangzhou University of Chinese
Medicine
Objective: To investigate the safety and feasibility of laparoscopic radical total gastrectomy with pancreasand spleen-preserving splenic hilum lymph node dissection for proximal advanced gastric cancer, and to
compare the early results of this procedure with open approach.
Methods: Between January 2013 and December 2014, 45 patients with upper third or middle third gastric
cancer underwent total gastrectomy with modified splenic hilar lymphadenectomy were enrolled. Patients
were assigned to the laparoscopy-assisted total gastrectomy group (LATG, n = 15) or the open total
gastrectomy group (OTG, n = 30). The operative and postoperative measures, number of retrieved lymph
nodes (LNs), and complications were compared between the two groups.
Results: Compared with the OTG group, the LATG group had less operative blood loss [130.938.3 versus
224.051.6 ml (P\0.001)], shorter time to ?rst ?atus [3.50.8 vs. 4.91.2 d (P\0.001)], earlier resumption
of liquid diet [4.30.6 vs. 5.21.1 h (P\0.001)], and shorter postoperative hospital stay [9.71.7 vs.
12.74.7 days (P\0.001)]. The mean number of dissected LNs (26.18.8 in the LATG group vs. 33.413.4
in the OTG group) and postoperative complications rates (6.7% vs. 10%) were not signi?cantly different
between LATG and OTG groups. However, LATG had a longer operating time than OTG [354.127.7 vs.
252.530.1 min (p\0.001)].
Conclusion: Laparoscopic radical total gastrectomy with pancreas- and spleen-preserving splenic hilum
LNs dissection is a safe and feasible procedure and has better early results than traditional open approach.

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P190

P191

The Alvarado Score for Appendicitis - Not As Sensitive As

Previously Indicated - A Retrospective Review

Management of Distal Esophageal Injury in Penetrating

Polytrauma

Isaac Payne, DO, Daniel Freno, MD, Jon Simmons, MD, Sidney B,
MPH, MD, University of South Alabama Medical Center

Farah Karipineni, MD, MPH, Lawrence Cetrulo, MD, Jay Strain, MD,
FACS, Mark Kaplan, MD, FACS, Pak Leung, MD, FACS, Albert
Einstein Healthcare Network

Introduction: The current literature suggests the Alvarado score is a highly sensitive and
specific clinical score for evaluation of patients suspected of acute appendicitis. We
hypothesize that although an Alvarado score [ 7 may positively predict appendicitis, CT
scan is still a more sensitive tool for predicting the diagnosis of appendicitis.
Methods: We retrospectively evaluated all patients from 2011 to 2015 who underwent
appendectomy for suspected appendicitis at our institution. A total of 107 patents were
included in the study, 96(90%) had a confirmed diagnosis of appendicitis on pathology. We
then compared CT findings and Alvarado scores with the patients final pathologic diagnosis. Sensitivities for the two groups were compared as well as predictive values.
Results: For an Alvarado score of [ 7, the sensitivity was 54% and specificity 64% with a
PPV of 91%. While CT scan had a sensitivity of 83% and a specificity of 45% with a PPV
of 93%. Of the 4 patients with negative pathology and Alvarado score of -[7, 3 had CT
scans positive for acute appendicitis and the remaining patient had a hemorrhagic ovarian
cyst on laparoscopy.
Conclusions: We conclude that in patients with Alvarado score \7 the diagnosis of
appendicitis cannot be excluded and thus warrant further diagnostic work up. CT scan is far
more sensitive for acute appendicitis than ALVARADO score and is a reasonable next step
in evaluating the patient with a low Alvarado score. Furthermore, in patients with an
Alvarado score of [ 7 there is no benefit in obtaining radiographic confirmation as a high
percentage of these patients will have acute appendicitis and appendectomy considered.

We report the case of a 22-year-old male who presented to our Level 1 trauma center after a
gunshot wound to the right hemiabdomen. He was initially tachycardic and hypotensive,
and was taken emergently to the operating room for laparotomy. On exploration he was
found to have massive hemoperitoneum, and a splenectomy and multiple gastrotomy
repairs were initially performed. He was also found to have a distal esophageal injury which
was temporarily controlled. Bilateral retroperitoneal hematomas were explored, revealing
shattered kidneys with bilateral hilar injury. At this time the decision was made to place a
temporary abdominal dressing and evaluate the patients renal system with CT angiogram
(CTA) prior to returning for possible nephrectomy. CTA confirmed bilateral grade V
kidney injury with active extravasation of both renal hila. CTA also displayed a grade IV
liver laceration involving segments 2, 4a, and 8, with active extravasation. The patient was
taken emergently back to the operating room where a right nephrectomy and liver segmentectomy were performed, with sparing of the left kidney. The patient was subsequently
taken to the interventional radiology suite for angioembolization of bleeding hepatic and
left renal arterial branches. He was then admitted to the surgical intensive care unit for
resuscitation and continuous renal replacement therapy. Over the next several days, he
returned to the operating room for reexploration and underwent pyloroplasty and Dor
fundoplication. He began to make adequate urine. His fascia was closed on hospital day
seven. He developed a urine leak on postoperative day eight, for which a ureteral stent was
placed. He was ultimately discharged home three weeks after admission in stable condition.
On follow-up, he has no evidence of gastric dumping or gas bloat syndrome, and is
tolerating an oral diet with no complaints.

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P192

P193

Acute Laparoscopic Management of Thoracoabdominal Gunshot

Wound

Laparoscopic Circular Stapling Esophagojejunostomy Following

Total Gastrectomy: A Simple and Reliable Suture-Tied-Anvil
Direct Insertion Technique

Siddarth Kudav, MD, Roger de la Torre, MD, Jacob A Quick,

University of Missouri - Columbia
Introduction: Penetrating thoracoabdominal trauma is often associated with hemodynamic instability,
precluding laparoscopic management. However, in hemodynamically stable patients, laparoscopy has the
ability to both effectively characterize injuries not reliably diagnosed via imaging techniques, as well as
provide a viable treatment modality. We present a case of a thoracoabdominal gunshot wound treated
acutely with laparoscopic techniques.
Case Presentation: A 27 year old male was evaluated in the emergency department after sustaining a highvelocity gunshot wound to the right chest. Physical exam revealed diminished breath sounds over the right
hemithorax, mild tachycardia, with a normal blood pressure and pulse pressure. Focused assessment with
sonography for trauma (FAST) revealed hemopneumothorax with no evidence of hemoperitoneum. Tube
thoracostomy was performed with return of air and 400 mL blood. The patient remained hemodynamically
stable and underwent contrasted CT imaging of the chest, abdomen and pelvis, revealing right lung injury
with hemopneumothorax, multiple rib fractures, and a Grade 2 liver laceration. On imaging, the missile was
seen with the right flank soft tissue. The presence of a liver laceration in the face of a gunshot wound to the
right chest was suggestive of diaphragmatic injury. The patient was taken emergently for diagnostic
laparoscopy. Upon identification of the diaphragmatic injury, pneumoperitoneum was decreased to 10
mmHg and thoracostomy collection container suction was confirmed. Our working ports were placed in a
similar configuration to a laparoscopic cholecystectomy, with the exception of a 10 mm epigastric port to
allow sutures to be passed. The laparoscope was inserted through the diaphragmatic injury and the chest
examined and hemothorax evacuated. The right lower lobe was contused, and the lung adequately inflated
without evidence of tension physiology. Ventilator peak pressures were kept under 30 mmHg. Hepatorrhaphy was performed laparoscopically with application of a topical hemostatic agent. Addressing the
diaphragm injury, two sutures were placed at the lateral edges of the injury and pulled through opposite ports
to allow the injury to be aligned properly, and was then repaired with interrupted nonabsorbable sutures. No
complications occurred and the patient was discharged following tube thoracostomy removal.
Conclusion: Selective acute laparoscopic management of penetrating thoracoabdominal wounds is safe and
effective in hemodynamically stable patients. Attention to pulmonary physiology is crucial to successful
laparoscopic completion.

123

Wei Wang, Wenjun Xiong, MD, Jin Wan, Yansheng Zheng, Lijie
Luo, Dechang Diao, Liaonan Zou, Guangdong Province Hospital
of Chinese Medicine
Objective: Anvil insertion is one main technically difficulty in intracorporeal esophagojejunostomy after
laparoscopic total gastrectomy. This study aimed to investigate the safety and feasibility of the suture-tiedanvil direct insertion technique for laparoscopic esophagojejunostomy.
Methods: After mobilization of the stomach and esophagus, the esophagus was ligated above the level
tumor. A semicircumferential esophagotomy was made at the anterior wall above the tumor. Then the
suture-tied-anvil was inserted into the esophagus with suture outside. A linear stapler was applied to transect
the esophagus adjacent to the incision left the suture not be cut. The stem of the anvil was pulled out by
drawing the suture for intracorporeal esophagojejunostomy after the negative rapid pathology result of
proximal margin confirmed. Anvil insertion time was defined from the semicircumferential esophagotomy
to the stem of anvil pulled out.
Results: From December 2011 to August 2015, 34 patients with proximal gastric cancer successfully
underwent totally laparoscopic radical total gastrectomy and intracorporeal esophagojejunostomy using a
suture-tied-anvil direct insertion technique. There was no reconstruction-related complication during
operation or conversion to open surgery. One patient developed anastomotic stricture that was resolved with
endoscopic dilatation. The mean operative time was 257.542.3 min within a mean anvil insertion time of
6.22.5 min and the mean esophagojejunostomy anastomosis time was 26.47.9 min. The mean blood loss
was 70.422.3 ml. The mean first time of flatus was 47.518.2 hours and the time of fluid intake was
55.617.2 hours. The hospital stay was 8.13.2 days.
Conclusions: Laparoscopic radical total gastrectomy with intracorporeal esophagojejunostomy using a
suture-tied-anvil direct insertion technique is simple, safe and feasible. This method is associated with
simplified procedures and reduced time of anvil insertion.

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P194

P196

Prospective FDA Feasibility Trial of Laparoscopically Placed

Temporary Diaphragm Pacing Electrodes: A New Reversible
Therapy to Treat Respiratory Failure

Laparoscopic Experience in Non-Traumatic Abdominal

Emergency

Raymond Onders, MD, MaryJo Elmo, Cindy Kaplan, Ajita S Prabhu,

MD, Jeffrey M Hardacre, MD, University Hospitals Case Medical
Center
Introduction: Acute respiratory failure requiring mechanical ventilation (MV) is a common life-threatening
result of varied diseases. MV comprises 30% of all Intensive Care Unit (ICU) admissions and 40% of MV time
is spent weaning. MV patients consume more resources, have longer ICU and hospital stays, and experience
more complications. Reducing MV is a priority for health care providers, administrators, systems and payers.
Diaphragm Pacing(DP) is FDA approved and is used in Spinal Cord Injury and Amyotrophic Lateral Sclerosis
to either replace, decrease or delay invasive mechanical ventilation. This reports use of a new temporary DP
electrode that will identify and treat respiratory compromise.
Methods: This was a prospective FDA (IDE #G150040); IRB approved (#4-15-03) and listed on clinicaltrial.gov (NCT 02410798) trial to evaluate the feasibility of temporary DP electrodes. This is a subgroup
analysis of the 4 abdominal laparoscopic procedures with subsequent implantation of DP electrodes.

Results: Four patients, 2 males and 2 females, successfully underwent placement of two
temporary electrodes into each diaphragm during a laparoscopic abdominal procedure. Ages
ranged from 61 to 80, with an average age of 67.8 years. Primary surgical procedures included
adrenalectomy (1) and benign foregut procedures (3). The subjects had multiple co-morbidities with an ASA of 2 to 3. Average BMI was 31.3 with a range of 24.3 to 37.0. At the end of
the primary procedure, DP electrodes were easily implanted and stimulated. Stimulation
settings, including amplitude, pulse width, frequency and inspiratory time, were adjusted to
achieve ideal tidal volumes. In three patients, stimulated tidal volumes exceeded the ideal tidal
volume by an average of 26.3% and in one patient ideal tidal volume was met. There was no
cardiac interference while stimulating the diaphragm at maximum settings. Postoperatively,
respiratory function was monitored by recording diaphragm EMG activity daily throughout
their hospital stay utilizing the temporary pacing electrodes. There were no complications
associated with the placement of the temporary diaphragm pacing electrodes and all 16 study
electrodes remained in place until removal prior to discharge. There was minimal pain
reported with complete intact removal of all 16 electrodes at the bedside.

Adrian Cotirlet, MD, PhD1, Marius Nedelcu, MD2, Laura Gavril3,

1
Moinesti Emergency Hospital, 2Nouvel Hospital Civil, IRCAD,
Strasbourg, 3Iasi University Hospital
Introduction: Progress in laparoscopic experience has increased the number of laparoscopic procedures
performed for nontraumatic abdominal emergencies. We present a retrospective study of the results of a
5-year experience at a single center with the intent to prove the safety and feasibility of laparoscopic
approach in the treatment of acute abdomen.

Methods: Between January 2010 to December 2014, 4461 patients were treated via
laparoscopy, including 1294 patients a provisional diagnosis of acute abdomen (29.01 %)
The following variables were analyzed: the final diagnosis, the conversion rate, the morbidity, mortality and the hospital stay.
Results: The final diagnosis was: 653 (50.46%) acute appendicitis; 421 (32.53%) acute cholecystitis; 52
(4.02%) gastroduodenal perforation; 146 (11.28%) gynecological emergency 22 (1.7%) small bowel
obstruction. A definitive laparoscopic diagnosis was possible in over 98% of cases, and definitive treatment
via laparoscopy was possible in 95.05 %. The conversion to laparotomy was needed in 64 cases: 42 (6.43%)
appendectomies; 12 (2.85%) cholecystectomies; 4 (7.69%) gastroduodenal perforation; 4 (2.73%) gynecological emergency and 2 (9.09%) small bowel obstruction. The overall postoperative morbidity rate was
4.32% and mortality was recorded in 2 cases. The mean hospital stay was 5.4 days.
Conclusions: The benefits of the laparoscopic approach in abdominal emergency are represented by both
high diagnostic accuracy and therapeutic options. Laparoscopy is safe and effective in treating gastrointestinal abdominal emergency with acceptable morbidity and low mortality rate. Compared with
laparotomy, the laparoscopy offers the advantages of less trauma, faster recovery, shorter hospital stay, and
lower postoperative complications rate for patients with acute abdomen.

Conclusions: This trial demonstrates the ease of placement, removal and functionality of temporary DP
electrodes. For patients that develop respiratory failure, laparoscopically placed DP wires can provide a
novel adjunctive therapy stimulating the diaphragm and potentially reducing MV.

P195
Comparison of Clinical Outcome and Prognosis in Patients
with Gastroesophageal Junction Adenocarcinoma
by Transthoracic and Transabdominal Hiatal Approaches:
A Single Chinese Teaching Hospital Retrospective Cohort Study
Shougen Cao, Yanbing Zhou, Jinzhe Zhou, Affiliated Hospital
of Qingdao University
Objective: To compare the clinical outcome and prognosis in patients with gastroesophageal junction
adenocarcinoma (Siewert type ? / ?) by transthoracic and transabdominal hiatal approaches.
Methods: 334 cases Siewert ?/? GEJ adenocarcinomas patients underwent different surgical procedures in
Affiliated Hospital of Qingdao University from July 2007 to July 2012 were analysed retrospectively. Of
which 140 cases by transthoracic approach, 194 cases by transabdominal hiatal approach mainly underwent
radical total and proximal gastrectomy(D2).All the patients were followed up by telephone review or
outpatients reexamination until July 2013. The surgical-related and clinical outcomes were compared using
the chi-square test, t test, Fishers exact test or nonparametric rank sum test according to different dates. The
survival curve was drawn by the Kaplan-Meier method and survival analysis used Log-rank test.
Results: The operative time, length of resected esophagus, number of lymph nodes harvested, postoperative
pain scores, postoperative hospital stay, time of antibiotics use, postoperative morbidity and costs, transabdominal surgery group was better than that of transthoracic group (20234 vs 15348. t=3.126,4.11.1
vs 3.81.1. t=2.634,177 vs 227. t=5.417, 5.91.8 vs 4.81.6. t=4.662,136 vs 116. t=2.030,6.82.4
vs 2.31.1. t=9.384,27.14% vs 15.46%. v2=6.841,4.71.8 vs 4.51.5. t=2.398,P \0.05) . The follow-up
rate was 90.42%(302/334) and the median survival time was 38 months in 272 months. The overall 5-year
survival rate was 35.3% and 40.3% respectively in transthoracic and transabdominal surgery group, there
were not statistically differences between them (v2 = 2.311, P [0.05). According to TNM staging, stratification analysis showed that that staging III patients overall survival rates were 25.7% and 37.2 %
separately, the difference was statistically significant (v2 = 4.127, P \0.05).
Conclusion: There was no significant differences of 5-year overall survival in TNM stage I and II of Siewert
II / III adenocarcinoma patients but improved survival of TNM stage III by transabdominal hiatal compared
with transthoracic radical total and proximal gastrectomy,There was more dominant short-term clinical
outcomes improving in transabdominal hiatial approach group.
Keywords: Gastroesophageal Junction Adenocarcinoma, Surgical Approach, Survival, Postoperative
Complications

P197
A Comprehensive Analysis of Entero-Cutaneous Fistulas
Suresh Khanna Natarajan, MD, Darwin P, MD, Stanley Medical
College & Hospital
Introductions: In spite of immense recent advancement in post-operative care, enterocutaneous fistulas
(ECF) remain one of the fascinating challenges because of their anatomical abnormalities, metabolic
derangement and associated extensive sepsis. They also remain to the surgeon the fallibility of surgical
technique and of the stress that falls upon both the surgeon and patient when major complications occur.
Method: Prospective analysis of ECF cases over one year was done from diagnosis till their discharge.
Details regarding type of surgery performed, category of fistula, their origin and their individualised
management policy were noted. Retrospective analysis was made to draw the principles for ECF prevention.
Fistulas arising from small bowel and colon were included. Those arising from pharynx, oesophagus,
stomach, biliary tract, rectum and anal canal were excluded.
Results: Among 20 ECF patients, 85% were postoperative, 10% traumatic and 5% malignant. Among the
postoperative ECF, appendicectomy (29.4%), perforation peritonitis (23.5%) and anastomotic leaks (17.6%)
were predominant causes. All of them had Ultrasound while 85% fistulogram and only 45% CT. 45% were
small bowel fistula, 40% colonic and 15% duodenal. Malnutrition (30%), sepsis (25%) and dyselectrolytemia (20%) were commonest adverse factors. Only the duodenal fistulas were high output (15%).
All patients were managed initially by conservative through a sequential planning phase for 46weeks
(compared to Sheldons four-phase management). Then surgery (70%, n=14) was done if there is no
likelihood of spontaneous closure. Parenteral nutrition (TPN) was used in 10% (n=2) during stabilisation
phase and were later switched to enteral nutrition (EN). EN was achieved in others by oral, nasogastric or
feeding jejunostomy due to non-availability or cost factors in TPN. We used three-category management for
ECF skin problems (compared to Irving-Beadles four categories).
Among conservatively managed ECF (30%, n=6), two died (10%) and four (20%) were successful. Among
surgical ECF, four (20%) had resection-anastomosis because of bowel defect [1cm and tract \2cm.
Remaining ten (50%) had proximal diversion stoma, care of ECF to allow spontaneous closure and stoma
closure after three months of which one died.
Conclusion: Surgery accounts for majority of cause for ECF. Anatomical origin, length of tract, bowel wall
defect, others like sepsis, malnutrition, malignancy, serum albumin are factors that influence spontaneous
closure. The importance of nutrition cannot be overemphasized. Definitive surgery is required in: no
spontaneous closure after 46weeks of conservative, complex fistula anatomy, including intra-abdominal
abscess, distal bowel obstruction, bowel defect [1cm diameter, fistula tract length \2cm.

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P198

P199

Optic Nerve Sheath Ultrasound for Bedside Diagnosis

of Intracranial Hypertension in the ICU: A Single Institution
Experience

Laparoscopic Nissen Fundoplication Using a Left Posterior

Approach Minimizes Esophageal Injury: Our Experience

Lisandro Montorfano, MD, Federico Perez Quirante, MD, Alejandro

Cracco, MD, Hira Ahmad, MD, Rajmohan Rammohan, MD, Nisha
Dhanabalsamy, MD, Alex Ordonez, MD, Emanuele Lo Menzo, MD,
PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS,
Raul J Rosenthal, MD, FACS, FASMBS, Cleveland Clinic Florida
Introduction: The aim of our study was to evaluate the ultrasonographic modifications
observed on the optic nerve sheath diameter in patients in the surgical ICU.
Material and Methods: We prospectively collected data from patients in the ICU between
March and August 2015. The optic nerve sheath diameter (ONSD) was measured sagittally
with a 12-MHz transducer. The ONSD was measured 3 mm posterior to the globe. Two
measurements were averaged. The measurements were obtained the second day of
admission in the ICU. We considered normal optic nerve sheath measures up to 5.0 mm in
diameter. If the patient had an abnormal measurement the optic nerve sheath diameter was
re-measured before discharge. Students T test was used to asses the statistical significance
of our findings.
Results: A total of 12 patients admitted to the ICU were included in this study. The mean
age of this population was 60 years old (range 4579). The mean weight and body mass
index was 82.5 kg (range 30122.47 Kg) and 31 kg/m2 (range 2343). The mean systolic
blood pressure was 116 mmHg (range 91152) and the mean diastolic blood pressure was
63 mmHg (range 4197).
When measuring the optic nerve sheath diameter for the first time we found that 6 patients
(50%) had a measurement lesser than 5.0 mm and 6 patients (50%) had a measurements
greater than 5.0 mm. The mean optic nerve sheath diameter was 4.69 mm (range 4.114.97)
for the first group and 6.09 mm (range 5.516.55) for the second group (p\0.001). The
second group included 2 patients that were intubated (16.6%), 1 patient that had sepsis
(8.3%), 1 patient had foregut surgery due to esophageal cancer (8.3%) and 2 patients had
neurologic complications, such as a CVA (8.3%) and cerebral aneurysms (8.3%). The optic
nerve sheath diameter was remeasured in those patients that had a first measurement above
5.0 mm. The second ONSD measurement was 4.79 mm in average. (range 3.775.5). The
difference between the first and second measurement was statistically significant (p= 0.02)
Conclusion: It is possible to detect raised ICP by measuring the Optic Nerve Sheath
Diameter (ONSD) using ultrasound in the ICU. Changes in the ONSD due to acute events
reflect a temporary and reversible increase in the ICP in the ICU. Further studies are
necessary to assess the benefit of this additional monitoring modality in terms of mortality
or morbidity in these patients.

123

Alicia J Mangram, MD, Francisco Rodriguez, MD, Olakunle F

Oguntodu, James K Dzandu, Honor Health John C Lincoln North
Mountain Hospital
Background: Laparascopic Nissen fundoplication (LNF) is now considered by most as the
gold standard in surgical treatment of GERD with hiatal hernia. The most feared complication of LNF is esophageal perforation. There are different approaches to create the 360
wrap. However, little has been reported on modified posterior approaches resulting in
improved patient outcomes. We present our experience with modified Laparoscopic Nissen
Fundoplication using the Left Posterior (mLNF-LP) approach to strategically minimize the
risk of esophageal injury.
Methods: This retrospective review identified patients who underwent fundoplication from
2012 to 2014. Data assessed were age, sex, body mass index (BMI). Indications for Nissen
fundoplication repair were: persistent GERD, hiatal hernia type, Barretts esophagus, or
recurrent GERD. Intra-operative and post-operative complications were assessed. Data
were analyzed using descriptive statistics. Details of the procedure are described.
Results: 171 patients underwent mLNF-LP. The average age was 6014 (range 1786)
years, males (29%) and the mean BMI was 29.86.2 kg/m2. Forty-seven percent of patients
(80/171) were obese. Indications for fundoplication were: persistent GERD (88%), recurrent GERD (11%), recurrent hiatal hernia (8%), Barretts esophagus (4%). Among the 171
patients, 158 patients underwent mLNF-LP and hiatal hernia repair, and 13 patients had
mLNF-LP alone. Intra-operatively, there were no esophageal perforations, splenic injuries,
inadvertent vagotomies, or other organ injuries. The operation time was 10020 minutes.
Overall 98.5% of patients returned for follow-up (median time to visit 20 days). Postoperatively, 39 patients reported dysphagia. Thirty-one of whom improved by their second
visit with only 21% (n=8) patients ultimately requiring endoscopic dilation. The following
endpoints and complications were noted during follow-up visit: inability to belch (.6%), gas
bloating (2%), diarrhea (11%), early transient recurrent reflux (11%), and epigastric pain
(19%). There was no pleural effusion (0%), early satiety (0%) or mortality (0%). Seven
percent of patients underwent revision surgery.
Conclusions: This mLNF-LP approach which strategically minimizes risk to the esophagus
is a safe and effective surgical procedure for select patients presenting with symptomatic
GERD and hiatal hernia. Moreover, this modified technique can potentially eliminate the
high morbidity and mortality of esophageal injury.

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P200

P201

Negligence to Nightmare: Gossypiboma - Case Reports

Abdominal Tuberculosis Mimicking Acute Abdomen: The Role

of Laparoscopy

Dr Sreejoy Patnaik, MS, SHANTI MEMORIAL HOSPITAL

PVT.LTD
Introduction: GOSSYPIBOMA describes a mass within a patients body comprising a cotton matrix surrounded by a foreign body
granuloma due to retained pieces of gauze; is an infrequent surgical complication & serious surgical malpractice resulting from
negligence. Either detected early due an exudative inflammatory reaction with the formation of an abscess or can present late as a
mass due to aseptic fibrotic reaction to the cotton material.
Case Report: First case was that of a 45 year old male presenting with pain abdomen & vomiting after an open cholecystectomy
done 2 months back and on laparotomy a surgical sponge was retrieved from jejunal lumen. Second is a female patient 45 yr old who
had fever and purulent discharge P/V 3 months after a vaginal hysterectomy and a gauze was found in the POD on opening the
vaginal vault. Third was also a female 36 year old with pain in epigastrium, vomiting & occasional rise of temperature, following
open cholecystectomy 3months back. After endoscopic confirmation of a foreign body a square size surgical sponge was removed
from the duodenum via laparotomy. The fourth one being the most interesting one where a 29 yr old female after a LSCS for a twin
pregnancy complained of mild lower abdominal pain and constipation and while she had been planned for a cholecystectomy and
repair of a divarication of recti, an accidental injury to the small bowel during first umbilical trochar entry led to discovery of a
surgical sponge in the bowel lumen partially obstructing it.
Discussion: Despite all considerations during operation the incidence of retained foreign bodies following surgery has a reported
rate of 0.01% to 0.001%, of which gossypibomas make up 7080%; only a third being correctly diagnosed. Symptoms either relate
to recurrence, occlusion or septic changes. With an infrequent incidence & frequent misdiagnosis, this surgical malpractice is easily
avoidable by mere watchfulness of the surgeon and rest of the OT staff. Simply keeping the sponge count and thorough exploration
of the operative field before & after the procedures and use of surgical textiles impregnated with radiological markers would not
only spare the patient of unnecessary morbidity but also the surgeon of serious medicolegal consequences.
Conclusion: Though a rarity it must be suspected in every post operative case presenting with pain, obstruction etc. once confirmed
gossypiboma is best removed by open surgery though laparoscopic and percutaneous removal has been reported in few selected
cases.

Ernesto Miranda-Cervantes, MD, Jorge Carmona-Cantu, MD,

Mauricio Castano-Eguia, MD, Aurora Guillen-Graf, Ulises CaballeroDelaPena, MD, Berenice Medina-Ortiz, Chistus Muguerza Hospital
Alta Especialidad / UDEM
Introduction: Tuberculosis remains a major global health problem, in 2012 it was estimated that there were 8.6 million new cases
and 1.3 million deaths from the disease.
In the past 2 decades the rate of active tuberculosis has decreased globally by 37%, but the reduction was primarily in pulmonary
tuberculosis, whereas extrapulmonary tuberculosis has remained stable.
The association of peritoneal disease with pulmonary tuberculosis has been reported in 20% to 50% of cases. Peritoneal tuberculosis
may originate from lymphatics (mesenteric lymph nodes) or through blood.
Case 1: A 21-year-old female with a four-day history of moderate abdominal pain of diffuse localization. Physical examination
revealed a normal contour abdomen, absent peristalsis, tense, and generalized tenderness with a positive Blumberg sign.
Case 2:A 38-year-old male with a two-week history of moderate epigastric abdominal pain and 38aC fever. Physical examination
found pain in the epigastrium followed by rebound tenderness.
Both patients underwent computed tomography (CT), where ascitic fluid with diffuse wall thickening of the peritoneum and
omentum was observed (Fig. 1).
During laparoscopy straw-like fluid was found with diffuse implants in the abdominal cavity (Figs. 2, 3). Pathology results described
a granulomatous chronic inflammatory process associated with tuberculosis.
Discussion: Peritoneal tuberculosis continues to be a latent problem in developing countries. Exudative ascites with abdominal pain
and fever is the classic presentation, representing 70% of the cases. But, the incidence of tuberculosis as a cause of ascites is reported
only in 2% of the patients with this clinical manifestation.
CT characteristics are attenuation values of ascitic fluid of 2045 HU and nodular and thickened peritoneum.
The previous cases demonstrated these same characteristics with inflammatory ascites and the thickening of the peritoneum.
Detection of Mycobacterium tuberculosis in the ascitic fluid is very difficult and it is positive on direct examination in 5% of cases
Conclusion: Laparoscopy is the preferred diagnostic technique, with a sensibility of 93% and specificity of 98%, besides not only
does it allow the inspection of the peritoneum but also allows the option of taking biopsies.

Fig. 1 .

Fig. 2 .

Fig. 3 .

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P204

Laparoscopic Management of Duodenal Perforation

1

AbdulAzeez Karam, MD , Nourah Alsharqawi, MD , Salman

Alsabah, MD, FRCS, FACS2, Khaled Alsharaf, MD, FRCS1, Ibtesam
Albader, MD, FRCS1, Mohammad H Jamal, MD, MEd, FRCS,
FACS, FASMBS3, 1Mubarak Hospital, 2Al-Ameeri Hospital, 3Kuwait
University Department of Surgery
Introduction: Duodenal perforation is a common acute surgical emergency. The use of
laparoscopic management as a method for the treatment of duodenal perforation is gaining
ground but is not routine in many centers. In this report we aim to report our experience
with laparoscopic repair of duodenal perforation.
Methods: This is a retrospective review of all patients undergoing repair of duodenal
perforation between 2009 and 2013. Patient demographics, diagnostic methods, management and outcomes were evaluated.
Results: A total of 67 patients underwent management of duodenal perforation. Diagnosis
was established by clinical examination and the presence of pneumoperitoneum in plain
abdominal X-rays in 50 patients (75%). 17 patients were diagnosed by CT scans in the
absence of x-ray findings. Laparoscopy was attempted initially in 51 patients (76%) and
completed in 47 patients (92%). No statistical difference was noted between the open and
laparoscopic group in terms of age, socioeconomic class, ASA score, duration of symptoms
prior to presentation and comorbidities. However length of hospital stay was shorter in the
laparoscopic group (mean =2.6) vs open group (mean=3.1) (P value=0.008). Complications
developed in 14 patients (20%) and were no different between the groups. No mortality was
identified in this cohort. In both laparoscopy and open surgery Graham patch repair was
performed to the perforated duodenum.
Conclusion: The use of laparoscopy in the treatment of perforated duodenal ulcer is safe
and can be utilized as the routine approach for the treatment of this pathology.

Unusual Presentation of Omental Sarcoma

Hany M Fahmy, MBBChFRCSIFACS, Fadi M Jallad, Raafat Bawadi,
Royal Commission Medical Center
Introduction: Although liposarcoma is common abdominal malignancy, yet mesenteric
primary liposarcoma is a very rare disease.
Case Presentation: We are presenting a 43 years old Saudi lady presented to our emergency department complaining of sudden onset of epigastric pain of 8 hours duration,
radiating to the back associated with vomiting and nausea. Positive history of peptic ulcer
disease and was on proton pump inhibitors treatment for the last 3 months. The patient was
hypotensive, moderately dehydrated, and with a board like rigid abdomen. Her plain x-ray
chest showed air under diaphragm. The patient was operated after resuscitation for
exploratory lapratomy. Exploration revealed a perforated duodenal ulcer part one with free
peritoneal fluid (bacteria peritonitis). After peritoneal toilet and suction of free fluid, we
noticed that firm masses of omentum (omental cack) which bleeds easily on touch are
clearly seen. The duodenal perforation was closed by graham patch using a flap from
falciform ligament due to abnormal consistency of the greater omentum. No other organ
masses could be seen. Biopsy of the diseased omentum was taken. Histopathological study
showed primary well differentiated liposarcoma. After improvement of the general condition of the patient, she was referred to oncology center for further management.
Conclusion: Omental sarcoma is a rare malignancy that can present with vague symptoms,
usually advanced and may present with unusual clinical presentation.

P205
Glove-Finger Extraction Technique for Laparoscopic
Appendectomy: High-Quality Cost-Conscious Surgery

P203
Comparison of Laparoscopic and Open Appendectomy: 5-Year
Single Center Experience
Ali Fuat Kaan Gok1, Yigit Soytas1, Sercan Yuksel1, Muhammed
Ucuncu2, Mehmet Ilhan1, Hakan Yanar1, Kayihan Gunay1,
Cemalettin Ertekin1, 1General Surgery, Istanbul Medical Faculty,
Istanbul, Turkey, 2Arnavutkoy State Hospital
Introduction: Acute appendicitis is the most common cause of acute abdomen and a major
part of the emergency surgical interventions. The aim of our study is to examine to
laparoscopic or open appen- dectomy cases demographic data, length of stay and morbidity.
Materials and methods: Between January 2008 June 2013 with the diagnosis of acute
appendicitis in 1490 patients who underwent sur- gery were analyzed retrospectively. The
data were analyzed with SPSS 16.0 software package.
Results: 546 laparoscopic cases (37 %), 944 cases open surgery (63%) underwent
appendectomy procedure. Mean age was 31.4 years of laparoscopic surgery group, open
surgery group was 33.7 years. 296 patients in the laparoscopic group (54 %) were male and
621 patients in open group (65 %) were male. the av- erage length of hospital stay was 1.5
days at laparoscopy group, 2.1 days at open surgery group. At laparoscopy group, the mean
length of hospital stay were significantly shorter than the open surgery group (p:0,003). 25
patients (4 %) at Laparoscopy group, 43 patients (4 %) at the open surgery group that
extends the length of stay or requiring re-hospitalization morbidity (superficial sur- gical
site infection and/or deep surgical site infection) were observed. There was no statistically
significant difference between the two groups
Conclusion: Laparoscopic surgery is preferred in terms of pa- tient comfort and earlier
return to work. Between the open surgery, and laparoscopic surgery, in terms of length of
stay and wound infection, was shown to be statistically significant dif- ference in favor of
laparoscopic surgery. With increased experience in laparoscopic surgery will increase for
treatment of acute appendicitis.

123

Sharique Nazir, MD1, Alex Bulanov, MS, DO2, Meghedy

Shanazarian, BS3, Jordan K Magruder, BS3, 1NYU Lutheran Medical
Center, 2NYIT College of Osteopathic Medicine, 3St. Georges
University
Introduction: Compared to an open appendectomy, the procedural costs of a laparoscopic
appendectomy (LA) are significantly higher, mainly due to the specialized instrumentation
required. Our goal was to investigate the use of an alternative specimen retrieval method
device in an LA to assess whether costs can be decreased without compromising the quality
of patient care.
Methods: We performed a retrospective chart review of all laparoscopic appendectomies
performed by an experienced minimally invasive surgeon at our 500-bed urban community
teaching hospital. Outcome parameters were duration of the operation, postoperative
complications (intra-abdominal abscesses, wound infections, and post-operative pain),
length of hospital stay, and readmission rate.
Technique: The laparoscopic appendectomy was performed in the usual fashion. However,
in lieu of a disposable specimen retrieval bag (e.g. EndoCatchTM), a glove-finger approach
was used. The middle finger of a size 8.5 brown glove is cut off at an oblique angle and
inserted via the 12mm umbilical port using a Davis and Geck grasper under the direct
visualization of a 5 mm camera. The finger is then held by its upper edge and the appendix
is slid completely in. The glove finger is then withdrawn through the 12mm umbilical port.
Results: Between 2012 and 2015, 128 laparoscopic appendectomies were performed, 49 of
which utilized the glove finger extraction technique. The OR time for the glove-finger
technique was 48 minutes, significantly shorter than the EndoCatch time of 58 minutes (p =
0.009). There were no significant differences in length of stay (p = 0.58). One glove-finger
patient had a post-operative fever and one had some abdominal pain: both were successfully
treated with acetaminophen, for a complication rate of about 4%. The EndoCatchTM group
had 6 complications of varying severity for a complication rate of 8%.
Conclusion: The greatest disadvantage of the laparoscopic procedure is its significantly
higher equipment cost compared to the open approach. Although our data suggest comparable outcomes for both techniques, this may be limited by our small sample size and
selection biases as to when to use the glove-finger. We propose that the glove-finger
extraction technique allows us to maintain an optimal standard of patient care while
reducing the financial burden of the LA by decreasing the use of disposable specimen bags
(EndoCatchTM cost: $69). Future studies with larger sample sizes are needed to confirm our
findings.

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P206

P207

Multivariate Logistic Regression Analysis of Postoperative

Complications and Risk Model Establishment of Gastrectomy
for Gastric Cancer: A Single Center Cohort Report

Therapeutic Strategy for the Super-Elderly with Acute

Cholecystitis A Single Center Experience for Ten Years

Shougen Cao, Hao Wang, Yanbing Zhou, Affiliated Hospital

of Qingdao University
Objective: To evaluate the risk factors of postoperative complications and establish logistic
regression model in a real life cohort of patients with gastric cancer following gastrectomy.
Methods: We retrospectively analyzed data on 2795 gastric cancer patients underwent
surgical procedure at the Affiliated Hospital of Qingdao University between June 2007 and
June 2012, established multivariate logistic regression model to predictive risk factors
related to the postoperative complications according to the Clavien-Dindo classification
system .
Results: 24 out of 86 variables were identified statistically significant in univariate logistic
regression analysis, 11 significant variables entered multivariate analysis were employed to
produce the risk model. Liver cirrhosis, diabetes mellitus, Child classification, invasion of
neighboring organs, combined resection, introperative transfusion, Billroth II anastomosis
of reconstruction, malnutrition, surgical volume of surgeons, operating time and age were
independent risk factors for postoperative
complications
after gastrectomy. Based on
P
P
logistic regression equation, P=Exp BiXi/(1+Exp BiXi), multivariate logistic regression
predictive model that calculated the risk of postoperative morbidity was developed, P=1/
(1+e(4.8101.287X10.504X20.500X30.474X40.405X50.318X60.316X70.305X80.278X90.255X100.138X11)). the accuracy,sensitivity and specificity of the model
to predict the postoperative complications were 86.7%,76.2% and 88.6%, respectively.
Conclusions: This risk model based on Clavien-Dindo grading severity of complications
system and logistic regression analysis can predict severe morbidity specific to an individual patients risk factors, estimate patients risks and benefits of gastric surgery as an
accurate decision-making tool and may serve as a template for the development of risk
models for other surgical groups.
Keywords: Postoperative Complications, Gastric Cancer, Surgery

Takeshi Yanagita, MD, Ken Hayashi, MD, PhD, Shigetoshi Yamada,

MD, Nobuyasu Kano, MD, PhD, FACS, Hiroshi Kusanagi, MD, PhD,
Kameda Medical Center
Introduction: Laparoscopic cholecystectomy (LC) has been reported to be safe and feasible even for the elderly. It is not clear, however, for what patients and under what
condition, LC for the super-elderly (eighty years old or older) with acute cholecystitis (AC)
can be performed the most safely and effectively. We performed retrospective review for
the total number of 962 patients to determine the best management for the elderly (between
65 years old and 79) and the super-elderly.
Methods: Between January 2005 and May 2015, 962 elderly patients admitted to the
Kameda Medical Center in Japan as a diagnosis of cholecystitis. Those patients were
excluded, who didnt satisfy the diagnostic criteria of Tokyo Guidelines 2013 for AC
(TG13), whose main problem was not AC (such patients as pancreatic cancer with
cholecystitis) and who had additional cholecystectomy during other surgical procedures like
gastrectomy.
The total number of 522 patients was eligible for this study. Age group was the primary
independent variable; 215 patients were at the age of 80 years old or older (the super-elderly
group: SG), and 307 patients were 6579 years of age (the elderly group: EG).
Each group divided into two subgroup; operative group (SG-O, EG-O) and non-operative
group.
Operative group was defined as those who had surgery performed during the index
admission or performed after initial non-operative management. Non-operative group was
treated without surgery all through their admission.
Continuous variables were analyzed by using the Mann-Whitney U tests. Chi-square and
Fishers exact tests were used for comparisons of categorical variables.
Result: Performance Status of Eastern Cooperative Oncology Group and serum albumin
level on admission were significantly different between operative group and non-operative
group.
There was significantly less complication (Clavien-Dindo classification more than 3a) in
SG-O when operations were performed in 7 days from onset or more than 60 days after nonoperative management. LC showed less hospital stay and less complication compared with
open cholecystectomy in both SG-O and EG-O, and also cost effective.
Conclusion: Firstly, PS and serum albumin level can be a strong determinant for indication
of surgery for the super-elderly.
Secondly, early LC should be performed for TG13 grade I patients if possible.
For TG13 grade II or III patients or those who take anticoagulants and/or antiplatelet agents,
percutaneous cholecystostomy should be placed, then LC or open cholecystectomy in seven
days from onset, or more than 60 days can be safely performed.

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P209

Bowel Perforation After Posterior Spinal Instrumentation:

A Rare Complication

Acute Presentation of Infected Urachal Cyst in Children: The

Role of Laparoscopy

Ernesto Miranda-Cervantes, MD, Luis Molina-Estavillo, MD, Ulises

Caballero-DelaPena, MD, Mauricio Castano-Eguia, MD, Aurora
Guillen-Graf, Marco Juarez-Parra, MD, Berenice Medina-Ortiz,
Christus Muguerza Hospital Alta Especialidad / UDEM

Ernesto Miranda-Cervantes, MD, Francisco C Sanchez-Garcia, MD,

Mauricio Castano-Eguia, MD, Marco Juarez-Parra, MD, Aurora
Guillen-Graf, Ulises Caballero-DelaPena, MD, Berenice MedinaOrtiz, Christus Muguerza Hospital Alta Especialidad / UDEM

Introduction: Intestinal perforation is a rare complication of lumbar instrumentation on a posterior approach. Until 2013 only 23 cases were
reported.
The L4L5 intervertebral space is the most frequent location of a herniated disk. Anterior to this intervertebral space separated only by the anterior
spinal ligament, we can find the bifurcation of the aorta, the vena cava and the abdominal cavity.
Case Report: A 43 year-old female presented with a 1-year history of back pain and radicular symptoms. Magnetic resonance imaging (MRI) was
requested reporting a herniated intervertebral space in L4L5 and L5S1. Surgery was scheduled performing a laminectomy with discectomy and
lumbar spinal instrumentation in the intervertebral spaces L4L5 and L5S1.
On her third postoperative day the patient referred diffuse abdominal pain. Physical examination revealed absent peristalsis and rebound tenderness,
without hemodynamic compromise.
Abdominal ultrasound was realized, and approximately 100 ml of pelvic free fluid was found. A computed tomography (CT) revealed air in the
spinal canal adjacent to the surgery site, pneumoperitoneum and free fluid in the paracolic gutter (Fig. 1).
Laparoscopy was performed finding abundant serohematic fluid and identifying an opening in the retroperitoneum posterior to the sigmoid colon of
about 1.5 cm, metal clips were used for vascular control (Figs. 2, 3).
After four days of the postoperative course the patient presented with abdominal pain, fever of 38  C, and leukocytosis of 33,000 K/ul, where a CT
scan reveled pneumoperitoneum
Afterwards, laparotomy was performed, finding abundant inflammatory fluid and perforation of the ileum 40 cm from the ileocecal valve: we
performed the resection of the affected segment and a latero-lateral anastomosis (Fig. 4).
Discussion: When the patient is in prone position, the abdominal pressure causes compression of the abdominal viscera against the vertebral bodies
and retroperitoneal vessels. Additionally, chronic disease can weaken the anterior spinal ligament, making the space between the vertebrae and the
retroperitoneum lessen, favoring the emergence of vascular or visceral lesions.
The clinical manifestations posterior to an intestinal injury by lumbar instrumentation are nonspecific. Pneumoperitoneum can be caused by
retroperitoneal perforation without intestinal damage and the bleeding may cause peritoneal irritation.
Conclusion: Early diagnosis can prevent fatal outcomes, so it is of great importance to include intestinal perforation in the diagnosis of patients with
abdominal pain posterior to lumbar instrumentation.

Introduction: The urachus is a structure that connects the bladder dome with the umbilicus. A urachal cyst occurs when both ends are obliterated but
the central portion remains patent. This types of cysts usually remain asymptomatic, and do not require medical treatment unless they become
infected. The most frequent clinical findings are infraumbilical painful mass, umbilical discharge, and sepsis.
Case Report: An 8-month-old male, product of a twin pregnancy (dichorionic-diamniotic) obtained at 35.6 weeks of gestation due to preterm labor,
with history of hydrocephalus and myelomeningocele treated with corrective surgery and peritoneal shunt valve placement at day 2 of extra uterine
life.
He arrived to the ER with a 4-day history of vomiting and decreased stool consistency; one-day prior admittance he progressed with bilious emesis,
hyporexia, irritability, hyporeactivity, and mild abdominal distension.
Physical exam of the abdomen revealed absence of peristalsis, a 2x2 cm peri-umbilical mass that was tender to palpation, no purulent or hematic
discharge was observed.
A complete blood cell count revealed a hemoglobin of 8.1g/dl, hematocrit of 24.2%, a leukocyte count of 19 550/mm3, and a platelet count of 694
104/mm3. C- reactive protein was elevated at 246.2 mg/dl. The remaining laboratory findings were within normal range. A plain abdominal film
revealed intestinal dilation of up to 3 cm and scarce distal gas in relation of an obstructive process (Fig. 1).
A nasogastric tube was placed and kept in observation for 12 hours without improvement. Upon surgical consultation, a diagnostic laparoscopy was
planned.
During the procedure, and infected urachal cyst was found along with free purulent fluid and distended small bowel loops (Figs. 2, 3). Intestinal
loops were freed and the urachal remnant was ligated at the vesical dome (Fig. 4).
Conclusion: The urachus and umbilical arteries lie in a extraperitoneal fascial plane, and it is extremely difficult for an urachal abnormality to
produce intra-abdominal symptoms. Urachal cysts causing intestinal obstruction are rare and diagnosis can be challenging, laparoscopy has proven to
be safe and feasible in the pediatric population.

Fig. 1 .
Fig. 1 .

Fig. 2 .
Fig. 2 .

Fig. 3 .

Fig. 3 .

Fig. 4 .

Fig. 4 .

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P212

General Surgery Education in Latin America: The Residents

Perspective. Initial Experience in Colombia and Panama

Emergent Reversal of Gastric Bypass Due to Severe GI

Hemorrhage from Marginal Ulcer Eroding Into Right
Gastroepiploic Artery

Juan C Correa, MD1, Maryam Elmi, MD1, Alvaro E Sanabria, PhD,

MD2, Carlos H Morales, MD, MsC3, Moises Cukier4, Frances C
Wright, MEd, MD1, Jaime M Escallon1, Oscar Henao1, 1University
of Toronto, 2Hospital Pablo Tobon Uribe, 3Universidad de Antioquia,
4
National Cancer Institute, Panama
Background: This study was performed to identify the strengths and weaknesses perceived
by Latin-American senior general surgery residents in their training.
Methods: A web-based survey was designed based on a previous experience in Canada,
tested in a focus group and then was sent via e-mail to 158 Colombian and 14 Panamenian
residents in their 2 final years of training (PGY 34 in Colombia, PGY 45 in Panama).
Demographic information, career plans, academic interests and perceptions of their technical and academic knowledge.
Results: The response rate was 54% in Colombia (86/158) and 57% in Panama (8/14).
63.8% of respondents were Male and 36.2 female. 55.8% of respondents in Colombia were
PGY3 and 50% were PGY 4 in Panama 50% were PGY4.
When asked to rate their laparoscopic training 31.8% thought it was poor or below average,
19% as average and 48.9% as above average or excellent. 54.55% of Residents did not
attend frequently a surgical skills laboratory (SSL) during their training.
94% of residents believe that strengthening surgical simulation programs should be a
priority in order to improve general surgery education in their country.
When asked how often they would require assistance while performing a laparoscopic
procedure as the primary surgeon: 65.5% requires assistance for a Laparoscopic Right
Hemi-colectomy, 67.8% for a Nissen Funduplication, 50% for a Laparoscopic inguinal
Hernia and 46.7% for a Laparoscopic Splenectomy.
Residents felt comfortable as primary surgeons in over 90% of all Open Inguinal hernias,
Laparoscopic appendectomies, Diagnostic Laparoscopies, Splenectomies and Open Right
Hemicolectomies.
53.2% of Residents are interested in pursuing a fellowship. 98% of respondents are
interested in an academic position and 83% want to continue performing research after their
residency is finished.
Residents believe that doing research would always or frequently provide them with better
job opportunities in 25% of opportunities, prestige in 51.1% and economic benefits in
6.82%
Conclusions: This study is a baseline to determine the educational objectives that residents
feel should be met. A great majority of residents want to work in an academic position, and
do research, but most of them feel that this is not often recognized with better employment
opportunities, salaries or prestige.
Over 54% of the residents dont have frequent training in a SSL, and 31.8% thought their
laparoscopic training needed improvement. Strengthening surgical simulation should be
and educational priority.

P211
Huge Retrorectal Cystic Teratoma Mimicking Menengitis.
A Case Report
Osman Nuri Dilek1, Hasan Kamil Sucu2, Ahmet Hakan Halici2, Turan
Acar2, Emine Ozlem Gur1, Oguzhan Ozsay2, Fulya Cakalagaoglu2,
Sedat Altay2, Mehmet Haciyanli1, 1Izmir Katip Celebi University,
School of Medicine, 2Ataturk Research and Education Hospital
Retrorectal primary mature cystic teratomas are extremely rare and can be challenging to
diagnose and treat in adults. These lesions are frequently clinically unrecognized and
misdiagnosed.
We present a case of a 39-year-old male patient with mature cystic teratoma presenting with
repeated episodes of menengitis. He presented to our emergency department with complaints of fever, headache and vomiting since 15 days. Neurological examination showed
that there was neck stiffness with positive Kernig and Brudzinski signs. On further enquiry,
he described similar episodes twice in past. Cerebrospinal fluid (CSF) analysis showed
lymphocytosis and elevated proteins. He was treated for initial diagnosis as tuberculosis
menengitis by a specialist of infection disease with antibiotics after a CSF study which was
culture negative. Since he had recurrent menengitis, radiological investigations revealed by
suggested it to be a retrorectal mature cyst 20 cm in diameter which may be related with the
cerebrospinal fluid. He underwent a total cyst excision of the lesion and histopathology
confirmed a mature cystic teratoma. The postoperative period was uneventful.
We identified about 25 cases of recurrent meningitis associated with dermoid and epidermoid cysts in the medline literature search. Here in, we discussed the diagnosis and
treatment modalities in view of the literature.

Nicholas Mouw, MD, Reid Adam, MD, John Mellinger, MD,

Southern Illinois University
Introduction: One of the known complications from roux en y gastric bypass is marginal
ulceration at the gastrojejunostomy. Marginal ulcers can present in many different ways
including gastrointestinal hemorrhage. This is typically due to erosion into the blood supply
of the bowel at the anastomotic site. Potential therapy for significant bleeding is endoscopic
control, angiographic embolization, or surgical revision.
Materials and Methods: We present a unique case of a severe GI hemorrhage caused by
erosion of a marginal ulcer into the right gastroepiploic artery in a 31 year old female status
post roux en y gastric bypass 5 years earlier. This recurred despite several endoscopic
interventions and angiographic embolization. Taking into consideration the patients
compliance, anatomy and severe malnutrition, the operative repair undertaken was emergent laparoscopic reversal of gastric bypass with resection of the roux limb, gastro-gastric
anastomosis, gastrostomy tube and jejunostomy tube placement. After a prolonged recovery
due to her malnutrition, the patient was discharged home in good condition. We reviewed
the literature regarding emergent revision and reversal of gastric bypass for acute GI
bleeding.
Conclusion: General surgeons should be involved early in the care of gastric bypass
patients with significant gastrointestinal bleeding from marginal ulcers. There are multiple
case reports for emergent revision of gastric bypass for GI bleeding in the literature.
However, there is little data regarding emergent reversal of gastric bypass for acute GI
bleeding.

P213
Changes in Morphological Condition of Small Intestine in Rats
After 50% Distal Resection of Small Bowel and After Correction
GLP-1 and GLP-2 Peptides
Ivan V Fedoriv, MD, Natalia V Sopchuk, MD, Volodymir F
Knygnytskyy, MD, Yuriy I Popovych, PhD, Department of human
anatomy, operative surgery and topographic anatomy IFNMU, IvanoFrankivsk, Ukraine
Introduction: The influence of GLP-1 and GLP-2 peptides in compensatory-renewal
mechanisms of small bowel after its 50% distal resection isnt fully researched.
Objective: The influences of GLP-1 and GLP-2 peptides, which are produced by L-cells of
ileum and colon have a trophic effect on leftover parts of small bowel and increase adaptive
processes.
Methods: 5 rats for each 7, 14, 30, 90 days after resection: without curation - intact 20 rats,
Glp-1 same days, so in total 20 rats, Glp-2 also 20 rats, and we were researching 3 parts of
leftover small bowel (jejunum, duodenum, ileum). All operations were done under
thiopental anesthesia.
Results: On the 7-th day after resection using Glp-1 we see decrease of wall thickness in
duodenum (58624,89) lm from (74211,74) lm - norm, jejunum without serious
changes, approximately, as in norm - (57313,86) lm and in ileum we signalize increase of
wall thickness (61221,12) lm from (40310,54) lm norm. After researching of Glp-2
action on the 7-th day after 50% resection we can make conclusion, that the wall thickness
increases in 1,3 times in duodenum and in 1,4 times in ileum, but in jejunum changes are
miserable, as in comparing with norm results.
On the 14-th day after resection using GLP-1 we have an increased wall thickness in all
divisions of small intestine, but the best is in ileum, more than 1.8 times as in control. And
after treatment of Glp-2 the biggest wall thickness we have got in duodenum (84816.24)
lm, but the biggest increase was in ileum 307 lm, jejunum 295 lm, more less in
duodenum 273 lm.
The laws of changes what we got on 14 days is almost similar with 7 days instead of
jejunum on the first 7 days we received an decrease of wall thickness even according the
control, on 14 days we have got a little increasing but it was still less than in norm
(decreasing both - height of villi and crypt).
Conclusion: compensatory-repairing reactions after distal resection of small bowel are
better when use GLP-2, because of increasing of wall thickness in almost all parts of small
intestine without abrupt falling of some exponents under using Glp-1(for example changes
in duodenum at 7-th day). So, using Glp-drugs is acquitted, in postoperative period.

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P214

P216

Laparoscopic Surgery of Symptomatic Urachal Remnants

Impact of Minilaparoscopic Versus Conventional Laparoscopic

Cholecystectomy on Recovery of Physical Activity:
A Randomized Trial

Takahiro Mizukawa, Norimasa Koide, Takao Kunou, Katsushi

Yoshida, Shigemi Onoue, Kenji Katou, Inazawa municipal hospital
Introduction: The traditional approach for removing a symptomatic urachal remnant has
been open surgery with a hypogastric transverse or midline infraumbilical incision. Recent
minimally invasive laparoscopic techniques can effectively manage this disease. We review
our experience with laparoscopic resection of an urachal remnant and report the efficacy
and outcomes of this procedure as a less morbid, minimally invasive alternative.
Methods and Procedures: Between June 2008 and June 2015, 17 patients (13 males, 4
females) with mean age of 28.2 years (range, from 12 to 43years) were included in this
study. Laparoscopic treatment was performed after patients acute symptoms subsided.
The visualization port using the Endopath Xcel 5-mm trocar placed on the right hemi
abdomen, and was insufflated by using CO2 with intraabdminal pressure maintained at
8mmHg. Another 5-mm port was placed under direct vision on the caudal side of the
camera port. .Another 2-mm port or 5-mm port was placed on the head side. The bladder is
filled with about 300ml of physiologic solution to help identify the bladder. The urachal
remnant was dissected from the umbilicus to the bladder dome, and then removed completely. The caudal side of urachal remnant was ligated with an intracorporeal knot and was
transected with ultrasonic scissors, just above the bladder dome. And then, the umbilicus
was excised with the umbilical remnant. Finally, we performed umbilicoplasty. Intra and
postoperative complications were analyzed to assess the safety and feasibility of the
procedure.
Result: As for chief complaint, 16 patients were pyogenic discharge from the umbilicus,
and 1 patient was pyuria. The mean day to operation after conservative treatment was 66
days (range, 2 to 262 days). The mean operative time was 167 minutes (range, 78 to 285
minutes). The blood loss was less than 10 ml. There were no conversion to laparotomy. The
mean hospital stay was 3.7 days (range, 3 to 9 days). There were no significant intraoperative or postoperative complications except 1 patient having small injury of
colonicserosa.
Conclusions: Laparoscopic resection of an urachal remnant was a safe and feasible procedure. This procedure provides satisfactory cosmetic results.

P215

Mohsen Alhashemi, MD, MSc, Mohammed Al Mahroos, MD,

FRCSC, Pepa Kaneva, MSc, Amy Neville, MD, MSc, FRCS, Melina
C Vassliou, MD, MED, FRCSC, FACS, Fried M Gerald, MD,
FRCSC, FACS, Liane S Feldman, MD, FRCSC, FACS, SteinbergBernstein centre of Minimally Invasive Surgery and Innovation,
Mcgill University Health Centre
Introduction: We conducted a randomized, double-blinded trial comparing minilaparoscopic cholecystectomy (ML-C) to conventional laparoscopic cholecystectomy (CL-C) to
determine if ML-C is associated with better recovery of physical activity after elective
surgery (NCT01397565).
Methods: 115 patients scheduled for elective cholecystectomy were randomized to either
CL-C or ML-C. Both procedures used a 10mm umbilical port, but the 3 additional ports
were 5mm in CL-C and 3mm for ML-C. Patients with upper abdominal surgery, acute
cholecystitis, ASA [3 and morbid obesity were excluded. The primary outcome was selfreported physical activity one month postop as estimated by CHAMPS questionnaire (kcal/
kg/week). Other outcomes were umbilical pain, abdominal pain and fatigue (VAS, 110),
and cosmetic result (1= worst, 5= best) at one and three months.
Results: Forty-three patients randomized to CL-C group and 36 patients randomized to
ML-C remained in the trial and were analyzed. In the ML-C group, 47% had at least one
5mm port mainly due to unavailability of ML equipment. The CL-C and ML-C groups were
similar at baseline in terms of age, gender and indication for surgery. Median (IQR)
physical activity for the CL-C and ML-C groups was similar at baseline (24.3(13.158.8) vs
23.4(14.274.6 kcal/kg/wk, p=0.44) and at one month (20(7.952.5) vs 16.5(11.626.6)
kcal/kg/wk, p=0.68). One month postop, while umbilical and abdominal pain were similar,
the CL-C group reported higher fatigue (4(15) vs 1(04), p=0.04) and lower scar
appearance scores (4(34) vs 4(45) vs p=0.02). At 3 months, the CL-C group had lower
scar appearance (4(35) vs 5(45) p=0.05).
Conclusion: Recovery of physical activity was similar after ML-C and CL-C while ML-C
resulted in less fatigue and better scar appearance. However, issues with instrument
durability limits widespread applicability of minilaparoscopic cholecystectomy

Traumatic Abdominal Wall Hernia: A Case Study of Blunt

Motorcycle Trauma

P217

Alisan Fathalizadeh, MD, MPH, Lawrence N Cetrulo, MD, Simran

Randhava, MD, Parkson Leung, MD, MSc, Albert Einstein Medical
Center

Emergency Surgical Management of Malignat Large Bowel

Obstruction

A traumatic abdominal wall hernia (TAWH) is a rare entity characterized by disruption of

the musculature and fascia of the abdominal wall with preservation of the overlying skin
layer following blunt trauma.The elasticity of the abdominal wall is protective against blunt
trauma such that the force becomes transmitted to internal organs thereby sparing the
abdominal wall. Thus, although blunt traumas have been on a rise, the development of
TAWH remains very rare.
A 28 year-old male previously healthy male presented to the emergency department following an auto versus motorcycle accident. He was ejected from his motorcycle and likely
skid on his abdomen. Upon presentation his primary survey was intact and he was
hemodynamically stable. He had multiple musculoskeletal injuries, anterior chest and
abdominal road rash, abdominal tenderness on physical exam. He had an equivocal focused
abdominal sonography for trauma (FAST) exam and ultimately underwent a CT abdomen/
pelvis demonstrating a traumatic ventral hernia as well as hemoperitoneum for which was
taken to the operating room. All of the fascial and muscle layers in the midline overlying
the area of the previous defect were found to be disrupted with bowel and mesentery present
under the intact skin layer. The source of the hemoperitoneum was identified as an isolated
hematoma in the small bowel mesentery in the area of small bowel that had herniated
through the fascial defect. This area of small bowel and the injured mesentary were
resected. The fascia was ultimately closed and a vac was placed in the subcutaneous layer.
Although a rare entity, familiarity with TAWHs is imperativative to allow for appropriate
management. Most literature advocate early repair of traumatic abdominal wall hernias in
that a failure to diagnose may result in incarceration or strangulation. Thus, despite the rare
nature of TAWHs, early recognition and surgical management is imperative in the care of
such patients.

123

Ahmedou Moulaye DRISS, MD, Faculty of Medicine of Nouakchott

Background: Majority of cases of acute large bowel obstruction are related to cancer. In
Mauritania more than 40% of patients with colorectal cancer (CRC) present with symptoms
of acute obstruction. There is a significant risk of mortality and morbidity in emergency
surgery for acute colonic obstruction and large number of patients will have a colostomy.
Patients and Methods: From January 2008 to December 2014, 150 cases of CRC are
managed in two institutions. Were included all patients with acute large bowel obstruction
operated within this period. Were excluded all cases with no malignancy. In this retrospective study sixty files analyzed statistically by SPSS system.Variables
wereage,gender,ethnicity,
history,clinical,biology,sndoscopy,Imaging,surgery,complications,pathology, chemotherapyand length of stay
Results: There were 42(70%) men 18(30%) women. Mean age 49(2372y) years. ArabBerber ethnic group (90%).History: tobacco(10%),diarrhea and/or constipation20%.
Occlusive syndrome present in all patients including pain,bloating,nausea and vomiting.
Abdomen X-ray and Ultrasound are contributory 50%. CT-Scann 60%. Operative risk
ASAIII 30%. All patients underwent surgical emergency. 18(30%) simple colostomy,
primary colonic resection 42(70%) cases. There were 6(10%) diastatic perforation and
3(5%) iatrogenic perforation. Biopsy with endoscopy was 18(30%) cases. Tumor seat was
right colon 12(20%) cases and left 36(60%) patients.Rectal seat 20%.Transfusion required
in 12 patients. Synchronous liver metastasis in 10%. Mortality rate was 20% and morbidity
30% (20% infection, 2 cases ureteral ligation). Carcinomatosis 20%. Length of stay 12 days
(719d). 30% of free margin section and adenocarcinoma were the most frequent (95%).
overall 5 years survival was 10% and 30% after 3years. Recurrence observed 18(30%)
times. Adjuvant chemotherapy performed 20% patients.
Conclusion: Despite significant progress,the management of acute colonic obstruction still
remains a challenge as well as both in developed and developing countries.The primary
resection was the most common procedure option in our study.In our country the poverty of
our technical platform and especially the lack of availability of stent use in our context may
explain the mortality and morbidity rates high in our study.

Surg Endosc (2016) 30:S325S500

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P220

Primary Care Physician and Care of Bariatric Surgical Patients

Survey

Outcomes of 1,159 Appendectomies Performed over 3 Years

at a Single-Institution, Safety-Net Hospital

Gadbois Kyle, MD, FACS, Hwang Stephanie, MD, Takata Mark,

MD, FACS, Fujioka Ken, MD, Fuller William, MD, FACS, Scripps
Clinic Medical Group

Ryan Dumas, MD, Madhu Subramanian, MD, Stephen Luk, MD,

Michael W Cripps, MD, University of Texas Southwestern Medical
Center at Dallas

Introduction: Obesity is a significant problem in the United States, 34.9% of adults are obese1. With more
than 100,000 patients undergoing bariatric surgery in the United States every year2, many post-operative
patients are being managed by their primary care physicians.
In a survey of primary care and subspecialty physicians, primary care physicians are only moderately
familiar with the National Institutes of Health (NIH) guidelines for bariatric surgery, and only moderately
familiar with the bariatric procedures that are currently performed3. Another study found 35% of surveyed
primary care physicians did not feel they had adequate resources to provide good quality long-term
medical care to operated bariatric patients and 45% of primary care physicians felt competent to address
the medical complications of obesity surgery.4
Methods: A 14 question survey was electronically sent to active PCP physicians treating bariatric patients in
the Scripps Clinic Medical Group. Surveyed physicians had a record of treating bariatric patients with no
type of bariatric surgery being excluded. An ordinal scale of five points was used ranging from Not Helpful
at All to Extremely Helpful. There was one final qualitative question allowing for a free text answer.
Results: The electronic survey was completed by 60 survey respondents out of 183 providers sent to (32.8%
response rate). There were eight free text, qualitative comments with respect to the surveys final inquiry.
Questions were split into three categories: post-operative medications, common post operative patient
concerns, and post operative laboratory and nutritional guidelines. Sixty-four percent of respondents
answered more guidelines on post-operative medications and laboratory and nutrional guidelines would be
extremely helpful. 42% responded that more guidelines on common post-operative patient concerns would
be helpful.
Conclusions: Primary care physicians in our medical group could benefit from more guidance in the
management of bariatric patients and more comprehensive guidelines.
References:

Introduction: Over the past few decades, the definitive surgical management of acute appendicitis has
shifted from open appendectomy (OA) to laparoscopic appendectomy (LA). This is mirrored by the reversal
in number of open versus laparoscopic appendectomies performed by graduating surgical residents during
this time. However, there is an ongoing discussion regarding use of LA because of potential increased rates
of intra-abdominal abscesses as well as a push towards conservative management alone. A single Emergency General Surgery (EGS) service does approximately 400 appendectomies per year at a high-volume,
safety-net hospital. We sought to identify current practice patterns, treatment strategies, and complications
from the surgical management of appendicitis.
Methods: A retrospective review was performed of all appendectomies done by the emergency general
surgery service at a large safety-net hospital from January 2012 to December 2014. Demographic data,
operative approach, comorbidities and complications were collected and reviewed. Chi square analysis was
done for proportion and nonparametric analyses were done where appropriate.
Results: 1,159 appendectomies were performed at our institution by 13 surgeons. There was a 2.7%
conversion rate from laparoscopic to open (n=32) and 3.9% were initiated and completed as an open
appendectomy (n=45). The remaining 93.4% (n=1,082) appendectomies were initiated and completed
laparoscopically. Over these three years, there was no statistical decrease in the conversion rate from LA to
OA, with the lowest rate occurring in 2014 at 1.9% (p=0.13). Approximately 10% of the cohort had
perforated or gangrenous appendicitis and the incidence of intraabdominal abscess (IAA) was 2.6%.
However, the incidence of IAA was 17.8% in those with perforation vs 0.95% in those without (p\0.001).
The median [IQR] time in days to definitive diagnosis of IAA from initial operation was 7 [5,9]. Serious
wound infection rates occurred in only 1.1% (n=13) of all patients. In the overall cohort, the incidence of
appendiceal tumors was 1.1% (n=13), the majority (n=10) consisted of low grade appendiceal mucinous
neoplasm. In this study, there were zero mortalities and the overall unplanned readmission to the hospital
was low at 4.4% (n=50).
Conclusions: Laparoscopic appendectomy continues to be a safe and effective method for treating acute
appendicitis. There is a very low conversion rate with no associated mortalities and minimal comorbidity.
There is a small rate of incidental appendiceal tumors and the overall incidence of IAA is low, but the risk
significantly increases in patients with perforated appendicitis.

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Childhood and Adult Obesity
in the United States, 20112012. JAMA. 2014 Feb 26; 311(8):80614
2. Livingston EH. The Incidence of Bariatric Surgery has Plateaued in the U.S. Am J Surg.
2010 Sep; 200(3): 37885
3. Avidor Y, Still CD, Brunner M, Buchwald JN, Buchwald H. Primary care and subspecialty management of morbid obesity: referral patterns for bariatric surgery. Surg Obes
Relat Dis. 2007 MayJun;3(3):392407.
4. Balduf LM, Farrell TM. Attitudes, beliefs, and referral patterns of PCPs to bariatric
surgeons. J Surg Res. 2008 Jan;144(1):4958

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P221

Variability in Management of Acute Calculous Cholecystitis:

An Institutional Survey

Laparoscopic Appendectomy: Risk Factors of Postoperative

Intraabdominal Abscess

Philippe Paci, MD, Pepa Kaneva, MSc, Julio F. Fiore Jr, PhD, Melina
C. Vassiliou, MD, MEd, Liane S. Feldman, MD, Steinberg-Bernstein
Centre for Minimally Invasive Surgery, McGill University Health
Centre, McGill University

Francisco Schlottmann, Romina Reino, Martin Galvarini, Jose

Alvarez Gallesio, Rudolf Buxhoeveden, Ezequiel Sadava, Nicolas
Rotholtz, Hospital Aleman of Buenos Aires

Introduction: Although literature and expert consensus support early cholecystectomy as definitive
management in acute calculous cholecystitis (ACC), variations in management practices persist. The
purpose of this study was to identify practice variations within a single institution including decision
for operative management or percutaneous cholecystostomy and management of concomitant biliary
obstruction, and to compare these practices with guideline recommendations
Methods and Procedures: A web-based survey was sent to faculty members and senior residents (CPGY3)
of a Canadian university-affiliated general surgery division at four academic hospitals. The faculty represent
surgeons with various subspecialty interests who also take general surgery/acute care surgery call. The
18-item survey was divided into 3 sections: demographics, management based on 8 clinical scenarios, and
perceived logistic barriers. Clinical scenarios varied in severity of ACC classified by the 2013 Tokyo
Guidelines, patient age and comorbidities, and risk of concurrent choledocholithiasis. Questions were
developed after identifying best practices using a structured literature search.
Results: From 74 potential respondents, 34 faculty members and 24 senior residents responded to the survey
(78% response rate). Of these, 85% performed at least 1 emergency cholecystectomy in the past year. For
mild ACC, 91% of respondents agreed with early cholecystectomy as optimal management. However, for
mild ACC in a comorbid patient (ASA3), this decreased to 65%, with the remainder opting for a cool
down period (22%) or cholecystostomy tube (13%). For mild ACC in an elderly healthy patient, only 62%
opted for early cholecystectomy, with 27% favoring nonoperative management and 11% placing a cholecystostomy tube. There was a range of preferences when the presentation included an intermediate risk of
choledocholithiasis, where guidelines recommend either intraoperative cholangiogram (IOC) or preoperative EUS or MRCP: 32% opted for ERCP, 20% for preoperative MRCP or EUS and only 27% chose to
perform an IOC. Regarding perceived barriers, 44% of staff cited lack of OR time as being responsible for
delaying early cholecystectomy. Barriers to IOC were increased OR time (cited by 29% of staff) and lack of
training (cited by 37% of residents).
Conclusion: Variations in opinions about best management of ACC were identified within a Canadian
university-affiliated general surgery division. While management was consistent with guidelines for
straightforward cases in healthy patients, increasing variability was seen as case complexity and patient
comorbidity increased. This information will be used to design a knowledge translation project targeting
gaps in management with best practice guidelines and identified barriers.

Introduction: Laparoscopic appendectomy (LA) has obtained wide acceptance over the last two decades.
However, several studies suggest there is an increased rate of intraabdominal abscess (IAA) after LA
compared with open appendectomy (OA). Since postoperative IAA is associated with high morbidity,
identifying predictive factors of this complication may help to prevent it. The aim of this study was to
identify preoperative and intraoperative risk factors of IAA after LA.
Methods and Procedures: From January 2005 to June 2015 all charts of consecutive patients underwent to
LA were revised. Demographics, clinical and intraoperative variables were analyzed. Independent risk
factors of postoperative IAA were determined by logistic regression analysis.
Results: A total of 1300 LA were performed. The mean age was 34.7 (1494) years. Two-hundred twentyfive patients (17.3%) had complicated appendicitis with perforation and peritonitis. The conversion rate was
2.3% (30 cases). Complicated appendicitis was the main cause of conversion (p\ 0.001). The average
hospital stay was 1.6 (027) days. There were 30 (2.3%) postoperative IAA. They were treated with
intravenous antibiotic (23%), percutaneous drainage (23%) or laparoscopic lavage and drainage (54%). In
the multivariate analysis, body mass index (BMI) [ 30 (p: 0.01), leukocytosis [ 20,000 / mm3 (p: 0.02),
perforated appendicitis (p \0.001) and operative time [ 90 minutes (p: 0.04) were associated with the
development of postoperative IAA. There was no mortality in the series.
Conclusion: Obesity, leukocytosis [ 20,000 / mm3, perforated appendicitis and surgical time [ 90 minutes
would be independent predictors of postoperative IAA. These findings suggest that in the presence of any of
these factors patients may require a close postoperative care in order to prevent or identify IAA after LA.

123

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P223

Efficacy of Laparoscopic Anti-Reflux Surgery for Non-Erosive

Gastroesophageal Reflux Disease Assessed by Combined
Multichannel Intraluminal Impedance-PH Monitoring

Laparoscopy in Trauma: Analysis of Publication History

and Study Demographics from 1925 to 2015

Fumiaki Yano, Nobuo Omura, Kazuto Tsuboi, Masato Hoshino, Se

Ryung Yamamoto, Shunsuke Akimoto, Takahiro Masuda, Koji
Nakada, Katsunori Nishikawa, Norio Mitsumori, Hideyuki
Kashiwagi, Katsuhiko Yanaga, Department of Surgery, The Jikei
University School of Medicine
Introduction: Due to the high prevalence of PPI resistance, treatment of non-erosive gastroesophageal reflux disease
(NERD) is challenging as compared to gastroesophageal reflux disease with reflux esophagitis (GERD). The aim of
this study was to investigate the therapeutic effects of laparoscopic anti-reflux surgery (LARS) for NERD using 24-h
combined multichannel intraluminal impedance-pH monitoring (MII-pH).
Methods and Procedures: Between February 2009 and August 2015, 30 patients (mean age, 48.5 years, 11 women)
who underwent LARS for NERD underwent MII-pH monitoring before and at 3 months after surgery. Reflux events
were classified by pH as acid or non-acid reflux. Intraesophageal pH\4 holding time (pH\4), longest episode,
episodes over 5 min, DeMeester score, and the numbers of acid and non-acid reflux episodes were calculated with the
patient in both liquid and gas reflux. The symptom index (SI) and symptom association probability (SAP) were also
evaluated.
Results: Twenty-six patients (87%) had hiatal hernia. The results of reflux events were listed on the Table 1. The
liquid pooling in the esophagus after surgery was possibly detected as non-acid gastroesophageal reflux. Both SI and
SAP improved significantly after surgery (p=0.011, 0.005).
Conclusions: 1) LARS for NERD completely controlled all acid reflux events and patients symptoms. 2) As
unidentified complaints after surgery, liquid pooling in the esophagus could be detected as non-acid gastroesophageal
reflux.

Table 1

Introduction: The use of laparoscopy in trauma surgery remains a debated topic. Although laparoscopic treatment of
injured patients has been discussed in the literature for decades, a consensus amongst trauma providers regarding its
use has yet to be reached. Our objective was to document the publication history of trauma laparoscopy and identify
any trends, as well as analyze study demographics, with hopes to better inform future areas of research.
Methods and Procedures: A Medline search was performed of English literature using the terms wounds, injuries,
trauma, and laparoscopy. The references of each article were also searched. Articles were excluded if laparoscopy was
not performed during the initial hospital admission. Year published, number of subjects, study design, mechanism,
type of laparoscopy, journal, and location of study were recorded. Type of laparoscopy is defined as: screening
(detecting signs of injury that are repaired via laparotomy), therapeutic (detection/repair of all injuries) or diagnostic
(identifying injuries/triaging patients as: injury free, with nonoperative injury, or with injury requiring further operative intervention).
Results: From 1925 to 2015, 201 English-language articles on trauma laparoscopy, encompassing 12,577 subjects, have
been published (Fig. 1). Type of studies include: 64 case reports(32%), 104 case series(52%), 22 reviews(11%), 5
randomized controlled trials(2.5%), and one systematic review(0.5%). Mechanism was blunt in 73 studies(36%, n=3707),
penetrating in 66(33%, n=4755), and 58(29%, n=4095) studies included both mechanisms. Type of laparoscopy performed
in each article was screening in 19(9%), diagnostic in 66(33%), therapeutic in 43(21%) and both diagnostic & therapeutic in
47(23%) (Fig. 2). The main journals involved were: Journal of Trauma (26 articles, 13%), Surgical Endoscopy (25 articles,
12%), Journal of Laparoendoscopic Surgery (11 articles, 5%) and American Journal of Surgery (11 articles, 5%). Fifty-four
percent (109 publications) originated in the United States, 31% in Europe (46 publications), and 8% in Asia (16
publications).
Conclusions: Trauma laparoscopy is becoming a tool in the armamentarium of the trauma surgeon, and the number of
publications examining laparoscopy to treat injured patients continues to grow. Over the past 90 years, the type of
laparoscopy performed has evolved from a screening tool into a diagnostic and therapeutic modality. Despite the large
number of publications, there is a need for adequately powered, randomized controlled studies to further support this
approach.

.
pH\
4HT

LE

[ 5 min

DM

LAR

LNAR

GAR

GNAR

TR

pre

3.84.9

11.515.1

2.03.0

13.515.9

32.625.9

34.427.2

3.88.2

15.617.8

83.251.2

post

0.51.1

1.83.7

0.20.7

2.44.0

8.314.9

27.125.6

0.81.2

12.511.2

48.438.2

\0.001

\0.001

0.004

\0.001

\0.001

0.121

0.04

p0.445

Nova Szoka, MD1, Lauren Coleman2, Gareth Gilna2, Dana Portenier,

MD1, Edward Auyang, MD, MS2, 1Duke University, 2University
of New Mexico

value
\0.001

meanS.D
pH\4HT; pH\4 holding time (%), LT; Longest episode (min), [ 5 min; episode over 5 min., DM; DeMeester score,
LAR/LNAR; Liquid acid reflux/non-acid reflux,GAR/GNAR; Gas acid reflux/non-acid reflux, TR; Total reflux

Fig. 1 Number of trauma laparoscopy publications per decade

Fig. 2 Type of trauma labaroscopy described in publications from

1925 to 2015

123

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P224

P226

Impact of the Surgical Safety Checklist on Postoperative Clinical

Outcomes in Gastrointestinal Tumor Patients

Non-Fluoroscopic Purely Endoscopic Stent Placement for Upper

GI Pathology: A Safe, Cost Effective Practice

Yanbing Zhou, Hao Wang, Affiliated Hospital of Qingdao University

Matthew J Lyon, Dr1, Paul Mousa, Dr2, Abheiney Jain, Dr3, Bimal
Sood, Dr4, Kamal Heer, MD5, Harish Kumar, MD1, 1University Of
Queensland, 2Prince Charles Hospital, 3Royal Free Hospital London,
4
Toowoomba Hospital, 5Monash Univeristy

Background: A 19-item Surgical Safety Checklist (SSC) was published by the World
Health Organization in 2008 and was proved to reduce postoperative complications. It was
issued by the National Health and Family Planning Commission of the Peoples Republic of
China in 2010. To date, however, the impact of SSC implementation in China has not been
evaluated. The study was performed to evaluate the impact of the SSC on postoperative
clinical outcomes in gastrointestinal tumor patients.
Study Design: Between April 2007 and March 2013, 7209 patients with gastrointestinal
tumor who underwent elective surgery at the Affiliated Hospital of Qingdao University
were studied. Data on the clinical records and outcomes of 3238 consecutive surgeries prior
to SSC implementation were retrospectively collected; data on another 3971 consecutive
surgeries performed after implementation of the checklist system were prospectively collected. The clinical outcomes (including mortality, morbidity, readmission, reoperation,
unplanned intervention and postoperative hospital stay) occurring within 30 days after
operation were compared between the two groups. Univariate and multivariate logistic
regression analysis were performed to identify independent factors for postoperative
complications.
Results: The rates of morbidity prior to and after checklist implementation were 16.43%
and 14.33% (P = 0.018), respectively. In-hospital mortality occurred in 0.46% of the
patients surveyed at the baseline and in 0.18% of the patients after checklist implementation
(P = 0.028). Median of postoperative hospital stay before checklist implementation was 1
day longer than that observed afterward (P \ 0.001). Multivariable analysis demonstrated
that the SSC was an independent factor influencing any postoperative complications (odds
ratio=0.860; 95% CI, 0.7500.988).
Conclusions: Implementation of the SSC could improve the clinical outcomes in gastrointestinal tumor patients undergoing general surgery in China.

P225
Current Trends in the Practice of Endoscopy Among Surgeons
in the United States
Joshua Tierney, MD, Rebeccah Baucom, MD, MPH, Michael
Holzman, MD, Benjamin Poulose, MD, MPH, Richard Pierce, MD,
PhD, Vanderbilt University Medical Center
Background: The diagnostic and therapeutic roles for endoscopic intervention are
expanding. A number of surgical diseases can now be treated endoscopically. To continue emphasis on endoscopy in surgical training, The Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES), has developed the Fundamentals of Endoscopic Surgery (FES) course to standardize and assess endoscopy training. However, little
demographic information exists about the current practice of endoscopy by general surgeons and how to best integrate endoscopic skills into surgical training.
Methods: A survey to collect data regarding the current practice patterns of endoscopy was
sent to surgeons with a valid email address in the American Medical Association masterfile.
The questionnaire included information regarding the type of training program each surgeon completed (academic vs. community general surgery residency) and their current
practice environment (academic medical center vs. community hospital). Additionally, the
respondents current practice volume of upper endoscopy and colonoscopy over the prior
year was stratified into three groups: rare (\1 per month), moderate (110 per month), and
frequent ([10 per month). Pearsons Chi-squared test was used to analyze the data from the
type of residency training and current practice setting in relation to the number of endoscopic procedures performed per month over the prior year of practice.
Results: The survey was sent to 9,902 general surgeons. There were 767 who provided
answers regarding their current practice of endoscopy. Mean time in practice was 18 10
years, 87 % were male, and 83 % practiced in a metropolitan area. Respondents who trained
at academic general surgery programs were less likely than those at community programs to
frequently perform colonoscopy (17.3% vs. 27.9%, p\0.05) and upper endoscopy (11.8%
vs. 17.1%, p\0.05). Those who currently practice in academic medical centers were also
less likely to be frequent performers of colonoscopy than those who practice at community
hospitals (5.6% vs. 24.7%, p\0.05). A similar result, though less pronounced, was found
comparing current practice patterns for upper endoscopy. There was a smaller proportion of
frequent performers of upper endoscopy in academic medical centers (9.8% vs. 14.8%,
p\0.05).
Conclusions: The type of residency training and current practice setting of general surgeons has a significant influence on the volume of endoscopic procedures performed.
General surgeons in community hospitals more frequently perform endoscopic procedures
compared to those in academic centers. This study identifies areas where more emphasis on
endoscopic skills training, such as FES, could be applied.

Introduction: Self expanding metal stents are widely used in palliation & treatment of GIT pathology. This study reports a single
surgeons results utilizing purely endoscopic technique without fluoroscopy.
Material and Methods: 201/202 [failed to intubate one] patients were stented using only endoscopic technique. Full or partially
covered distal release stents with or without anti-reflux mechanism were used. The stent was placed over a guide wire and opened
under endoscopic visual control. Final position was assessed endoscopically. All patients were allowed fluids orally within two hours
of procedure once they were fully awake. All procedures were done under appropriate sedation.
Results:

Demographics
Pathology [Total Number] [201]

Average Age [MinMax]

Male:Female

Esophageal/Upper Gastric[161]

75 years [4692 years]

8 M:79F

Pyloric/Duodena [11]

78.9 [6990 years]

8M:3F

Post Resection Leak [6]

66.7 [5076 year

4M:2F

TOF/Others[6]

58.5 [1784]

6M: 0F

Post bariatric Surgery Leak[17]

49.3 [2673 years]

7M:10F

Duration of stents
Number of
Patients

Pathology

Duration of stent

161

Esophageal/Upper Gastric
carcinoma

Natural Life

17

Post Bariatric procedure Leak

313 Weeks

11

Duodenal/Pyloric Obstruction

10 lifelong/1 removed in lymphoma

patient

12

Post Esophageal Surgery leak/

TOF

412 weeks

Of the 161 cancer patients 6 were already inpatient. Of the rest, 142/155, were treated as a day-case. 12 stayed overnight for social
reasons or discomfort.
80 of the cancer patients required dilatation before stenting. Balloon dilatation was used to facilitate intubation. One patient with
upper esophageal cancer was unable to be intubated.
7 patients had another procedure to add another or reposition the existent stent.One patient had chest pain post procedure and an
elevated white cell count but no radiological evidence of leak. Patient improved with 48 hours of antibiotics and was discharged on
fourth day.
There was no 30-day mortality. There was no clinical or radiological evidence perforation despite one suspected perforation.
Conclusion: Purely Endoscopic Upper GI stenting is versatile, safe and saves cost of fluoroscopy and radiographer and excludes
risks of radiation.

P227
The Role of Flexible Endoscopy in Reducing Anastomotic Leak
in Colorectal Anastmosis
Ahmad Othman, MD, Angel Morales-Gonzalez, MD, John Mistrot,
Stacey Milan, MD, FACS, TTUHSC at El Paso
Introduction: Anastomotic leak (AL) following colorectal anastomosis has been associated with higher morbidity and mortality,
increased length of hospital stay and increased cost of care. The use of flexible endoscopy in evaluating colorectal anastomosis can
document its integrity and assist in performing a controlled air-leak test. We hypothesized that evaluation of colorectal anastomosis
using flexible endoscopy would reduce the incidence of AL.
Methods and Procedures: This is a retrospective cohort study that includes all adult patients who underwent sigmoid resection with
colorectal anastomosis performed at a single academic institution between 2002 & 2012. Continuous variables were described using
mean and standard deviation while categorical variables were described using frequency and percentages. Continuous cofactors
were compared between patients with and without anastomotic leak using t-test or Mann-Whitney test. Categorical cofactors were
compared between patients with and without anastomotic leak using Fishers exact test. Variables with p-value less than 0.05 were
considered as statistically significant variables. All the analysis was done using SAS 9.3 statistical software.
Results: Our cohort included 178 patients. Mean age of the patients were 53 (SD=13.7) years. 14 (7.9%) patients developed AL and
had a hospital LOS three times longer than patients who did not. 25 (14.2%) were performed laparoscopically with a conversion rate
of 52%. 160 (90.9%) were elective procedures performed for colostomy reversal (36%), colorectal cancer (31%) and diverticular
disease (25%). Only 11 (6.9%) of the elective procedures developed AL while 3 (18.8%) non-elective procedures developed AL (Pvalue = 0.078). 8 (15.7%) of the diabetic patients developed AL while only 6 (4.7%) of the non-diabetic patients developed AL (Pvalue = 0.026). All patients who underwent endoscopic evaluation of their anastomosis were elective procedures performed on nondiabetic patients. None of the patients who had their anastomosis evaluated with flexible endoscopy developed AL while 14 (9.7%)
of those who did not undergo flexible endoscopy developed AL.
Conclusion: Endoscopic evaluation of colorectal anastomosis may reduce the incidence of AL.

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P229

Efficacy of Endoscopic Management of Leak After Foregut

Surgery with Endoscopic Self-Expanding Covered Metal Stent

Endoscopic Sphincterotomy with Bile Duct Stone Extraction:

Safety, Efficacy and Outcome in an Outpatient Unit

Amir H Aryaie, MD, Jordan Singer, BS, Mojtaba Fayezizadeh, MD,

Jeffrey Marks, MD, University Hospitals Case Medical Center

Michael Vitale, MD, Digeclinic, Guatemala City, Guatemala

Introduction: Anastomotic or staple line leak after foregut surgery presents a formidable management challenge. In recent years,
with advancement of endoscopy, self-expanding covered stents has been gaining popularity. In this study we aim to determine the
effectiveness of self-expanding covered stents in management of leak after foregut surgery.
Methods: Consecutive patients who received a fully covered self expandable metal stent (FSEMS) due to an anastomotic leak after
upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and
removal, clinical success, time to resolution and complications were collected. Predictive factors for clinical success rate were also
assessed.
Results: A total of 26 consecutive patients underwent placement of fully covered self expandable metal stents for anastomotic leak,
following gastric sleeve (n=5), esophagectomy (n=5), gastric bypass (n=4), total gastrectomy (n=3), partial gastrectomy (n=3), and
others (n=6). All the stents were removed successfully, and clinical resolution was achieved in 21 patients (81%) after a median of 2
(range 13) procedures, a median of 2 (range 14) stents, and a median of 42.5 (range 399) days. Complications presented in a total
of 14 patients (54 %), including stent migration (n=11), tissue integration (n=2), bleeding (n=1), which in 1 cases required surgical
intervention. One (4%) patient died due to a stent related cause. No type of surgery or particular patient factor, including age, sex,
BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with
success rate or time to resolution of leak.
Conclusion: Self-expanding covered stent is an effective tool for the management of leaks after foregut surgery. The biggest
challenge with this approach is stent migration. Larger studies are needed to determine factors predictive of success.

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Introduction: In the minimally invasive era, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is the treatment of choice for patients with bile duct stones. Endoscopic stone extraction is successful in over 96% of
patients, with a low procedure-related morbidity (5.8%) and mortality (0.2%). The purpose of this study was to assess safety,
efficacy and outcome in an outpatient unit for endoscopic stone extraction.
Methods: A retrospective review was carried out of patients undergoing ERCP with ES for bile duct stones performed at the surgical
endoscopy outpatient unit between October 2011 and September 2014. Procedures were performed by a single surgical endoscopist.
Pre-procedure diagnosis was reached by evaluating liver function tests, ultrasound, T-tube cholangiogram or magnetic resonance
cholangiopancreatography.
Results: 381 procedures were performed on 374 patients (64% women), mean age 35 years (range 16 to 77 years). Indications for
ERCP with ES and stone extraction were: choledocholithiasis (58.3%), retained bile duct stones (26.2%) and recurrent bile duct
stones (15.5%). Endoscopic sphincterotomy with stone extraction was performed in 301 (80.5%) patients, pre-cut sphincterotomy
with stone extraction in 56 (15%) patients and 17 (4.5%) patients were not successful for stone extraction. Endoscopic stone
extraction was successful in 95.5%. Of the 17 patients, in which endoscopic approach was unsuccessful, 7 were from the choledocholithiasis group. These patients were managed with an insertion of a biliary plastic stent and scheduled for a second ERCP.
Lithotripsy with successful stone extraction was performed at second procedure. Ten patients were taken to surgery, 8 of them were
from the retained bile duct stone group which underwent open common bile duct exploration. The remaining two patients were from
the recurrent bile duct stone group and presented with impacted stone at the ampulla of Vater. Transduodenal sphincteroplasty was
performed on the 2 patients. Complications occurred in 23 patients (6.1%): mild pancreatitis (3.2%), sphincterotomy bleeding
(2.6%) and moderate pancreatitis (0.3%). Procedure-related mortality was 0%.
Conclusions: Our study demonstrates that ERCP with ES and bile duct stone extraction performed in an outpatient facility is safe
and effective. The success and complication rate obtained in this review is within the expected range reported in the literature.

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P230

P231

Early Diagnostic Colonoscopy in Complicated Sigmoid

Diverticulitis: Feasibility and Risks A Prospective Study

Endoscopic Management of Acute Visceral Perforation

Marty Zdichavsky, MD1, Dietmar Stuker, MD1, Dorte Wichmann,

MD1, Jessica Lange, MD1, Martin Goetz, MD2, Alfred Konigsrainer,
MD1, Thomas Kratt, MD1, 1Department of General, Visceral
and Transplant Surgery, University Hospital Tubingen, 2Department
of Gastroenterology, Hepatology and Infectious Diseases
Introduction: Early colonoscopy in acute complicated sigmoid diverticulitis is usually
avoided but might give essential information prior to early-elective surgery. The aim of this
prospective clinical study is to evaluate feasibility and safety of early in-hospital colonoscopy in acute complicated sigmoid diverticulitis.
Methods and Procedures: 65 colonoscopies in 62 patients were performed early in acute
sigmoid diverticulitis. Patients with free perforations were excluded. All patients received
initial CT scans and were designated for early-elective sigmoid resection. Indications for
colonoscopy were no colonic examination in the past year to exclude malignancies and
chronic inflammatory bowl diseases. Patients data, white blood cells (WBC), C-reactive
proteine (CRP), CT scans, endoscopic and histological findings, and complications were
evaluated.
Results: Of all 62 patients, grading of CT scans showed in 64.5% covered perforations of
the sigmoid colon. Mean interval between acute attacks until colonoscopy was 6.0 days
(range, 012 days), mean time for colonoscopy 20.5 min (range, 1080 min). In 86% of
cases colonoscopy was completed. In 26.2% of patients polypectomies were performed
without complications with benign results histologically. In one patient with a not passable
sigmoid stenosis iatrogenic perforation occurred and in another one carcinoma was not
detected visually, but revealed histologically.
Conclusions: Early colonoscopy after an attack of acute complicated sigmoid diverticulitis
is safe and effective with a very low risk of complications. Caution should be taken in
patients with high-grade post-inflammatory stenosis. Prior to early-elective surgery for
sigmoid resection significant pathologies can be detected that might interfere with the
surgical strategy.

Kayla J Smith, MD, Brian Lane, MD, Georgia Regents University

Introduction: Endoscopic stenting with fully or partially covered self-expandable metallic
stents (FCSEMS) has become an effective and first line treatment for many esophageal and
bariatric surgery re-lated perforations and leaks. The use of FCSEMS has not been used
routinely for peptic ulcer or gastric ulcer related perforations, when traditional surgery may
be contra-indicated. We describe a case of the use of a FCSEMS to treat a large perforated
gastrojejunal ulcer in a 58 y/o male patient with a history of antrectomy and roux en Y
reconstruction for recurrent ulcer disease as well as 9 prior upper abdominal laparotomies, 3
of which were for ulcer disease, and the remaining for recurrent hernia with mesh and
jejunal fistula repair. This scenario obviously raised the concern for a frozen abdomen.
Methods: Patient chart review was performed.
Results: Emergency CT scan confirmed free air and amount of contrast extravasation. The
patient was septic on presentation and after aggressive resuscitation was brought to the OR
and placed under GETA. Given our concern for a frozen abdomen, we performed gastroscopy with CO2 insufflation. The endoscopic exam confirmed the history of a past
antrectomy with roux en Y reconstruction. A large 2.5 cm perforation was seen to the right
of the gastrojejunostomy. A wire was placed into the jejunal roux limb and a Boston
Scientific 23 x 125 FCSEMS was placed under fluoroscopic guidance. Given the large
right-sided abdominal abscess and the patients tense abdominal distention from the
endoscopic insufflation, we opened the far right lateral abdomen safely and performed
abscess drainage and left a sump drain.
The patient improved rapidly with decreased tachycardia and abdominal distention. His
ICU and hospital course were mostly unremarkable except for repeat endoscopy to reposition the stent with clips and to place a naso-duodenal feeding tube. Serial KUBs were
done to ensure no further stent migration. Stent removal was performed at 12 weeks post-op
after complete healing of the ulcer was seen. Subsequent H.Pylori and gastrinoma workup
was negative. The patient has been kept on long term PPI therapy and remains asymptomatic and well after one year.
Conclusion: FCSEM stent placement was safe, feasible and effective in this patient with a
large perforated gastro-jejunal ulcer and a frozen abdomen. Further studies and methods of
improved stent fixation are needed to determine if this approach is feasible for other typical
peptic ulcer perforations.

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P233

Evaluation of Diagnostic Performance and Visibility

in the Enhancement Processing of the Endoscopic Image

The Effects of Occupying the Working Channel on Endoscopic

Manipulation

Ito Takumi1, Hiroshi Kawahira2, Toshiya Nakaguchi2, Zenbutsu

Satoki2, Nakashima Hirotaka3, Masahito Inoue4, Youichi Miyake2,
1
Department of Medical System,Division of Artificial Systems
Science,Graduate School of Engineering,Chiba Univesity, 2Center
for Frontier Medical Engineering,Chiba University, 3Foundation
for Detection of Early Gastric carcinoma, 4Department of Endoscopic
Diagnostics and Therapeutics,Chiba University Hospital

Conor OShea, MEng1, Khan Kashif Ali2, Josef Tugwell, MEng1,

Marcus P Kennedy, MD2, Padraig J Cantillon-Murphy1, 1University
College Cork, 2Cork University Hospital

Introduction: In the current endoscopic examination, there is an electronic endoscope

system of FICE to improve the accuracy of diagnosis by an image processing. FICE selects
wavelengths from the spectral image obtained by the spectral estimation processing and
reconstructs the endoscopic image. It stressed such as a blood vessel image and pit
pattern
by FICE, has enabled support for diagnosis. However, when the shade of the image is
changed extremely, it would hinder the exact diagnosis. In this study, it is an object to
establish a standard of wavelength combinations in consideration of the shade of the image.
Method: We conducted 5 stages of the subjective evaluation experiment that compares 100
sheets of FICE image created by random and normal with naked eyes. The subjects were 7
people, two MDs (one expert endoscopist and one gastrointestinal surgeon) and five nonhealth care volunteers (three males and two females in early twenties). About evaluating
items, we defined visibility to evaluate the unnaturalness of the image and diagnostic
ability to evaluate the diagnostic capability of the image. About analyzing item, we
defined the color difference between background frame (organization of normal body) of
the normal endoscopic image and the background frame of the FICE image as color
difference of background. In addition, we defined the color difference between the target
frame (blood vessels and lesions) of the normal endoscopic image and the background
frame of the normal endoscopic image and the color difference between the target frame of
the FICE image and the background frame of the FICE image as FICE image color difference over normal endoscopic image color difference (Fdond). We analyzed the
relationship between subjective evaluation value, the background change color difference
and Fdond, the wavelength combination.
Results: There was some possibility to have a relationship among Visibility, diagnostic
ability, the color difference, the wavelength combination. In addition, we had different
results in the MDs and non- health care volunteers.
Conclusion: We speculated that the shade of the endoscopic image might affect the
diagnosis. We increase the evaluator, such as MDs, and will consider a valid wavelength
region in the future.

Introduction: This work aims to evaluate the hypothesis of reduced control with the
introduction of endoscopic instruments in the working channel of an endoscope. Despite
numerous studies demonstrating the safety and efficacy of endoscopic ultrasound, anecdotal
reports suggest that the articulation of many flexible scopes become limited with the
introduction of instruments in the working channel. This is exasperated in ultrathin scopes
where the ultrasound array may impede manipulation ability.

Methods and Procedures: An Olympus Evis Exera BF-1T160 scope (n=1), Olympus BF
UC260FW (n=1) and the Pentax EB-1970UK (n=2) were used to assess the hypothesis. Benchtop experiments measured the deflected up and down angle of the distal end with and without
endoscopic instruments present. Aspiration needles and biopsy forceps of varying cross sectional diameters (21, 22 & 25 gauge) were introduced in a sequential manner and were extended
to fixed distances beyond the distal tip. The corresponding tip deflection was measured using
graphical analysis (AutoCad 2014) and was compared to the manufactures specifications (see
Fig. 1). The scopes used in the study were selected due to their prevalence within national
health centres and all scopes were confirmed to be in full working order in advance of the study.
Results: The results of the physical experiments highlight a clear reduction in distal end
scope flexibility when actuated with endoscopic instrument present (see Fig. 2). Instruments of larger cross sectional diameter tend to further exacerbate controllability.
Furthermore the distance for which the instruments extend beyond the distal tip effects the
accuracy of targeting by adding to the mechanical stiffness of the scope when positioned
within the flexible distal end.
Conclusions: This study examines the hypothesis that scope control is diminished when
endoscopic instruments are introduced in the ultrathin scopes working channel with an
ultrasound array. Despite a limitation in the number of available test scopes (n=4), this
study has identified a clear correlation between reduced scope mobility and the introduction
of endoscopic instruments. The inclusion of an endoscopic instrument adds significantly to
the mechanical stiffness of the distal end, preventing a tight radius of curvature. This
observation becomes particularly critical during tortuous navigation, however future
advancements such as flexible needles and ultra-thin scopes may improve manoeuvrability.

Fig. 1 .

Fig. 2 .

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P236

How Many Annual Colonoscopies Are Required to Maintain

Competence for Surgeons?

Treatment of Biliary Disease with Transgastric ERCP After

Roux-En-Y Gastric Bypass

David Pace, MD, Mark Borgaonkar, MD, Brad Evans, MD, Curtis
Marcoux, Felicia Pickard, Vanessa Falk, Jerry McGrath, Darrell
Boone, Chris Smith, Memorial University

Mohammad Farukhi, MD, Benjamin Clapp, MD, Brian Davis, MD,

Jennifer George, MD, Texas Tech School of Medicine

Introduction: To determine if the annual case volume of general surgeons (greater or less than 200
colonoscopies) is associated with quality outcomes.
Methods: This retrospective cohort study involved all adults who underwent colonoscopy by a surgeon in
the city of St. Johns, NL during the first 6 months of 2012. Subjects were identified through records from
the health authority and data was extracted from the electronic medical record (EMR), including the
endoscopy procedure report, the nursing record of the endoscopy, and the pathology report. Data was
recorded on a standardized data sheet and entered into SPSS version 19.0 for analysis. Univariate analysis
was done to determine if there was an association (p\0.10) between quality outcomes (colonoscopy
completion rate, adenoma detection rate) and predictors of these outcomes including annual colonoscopy
volume, patient age, gender, indication for colonoscopy, and ASA score. Step-wise multivariable logistic
regression was then performed to see which variables were independently associated with these quality
outcomes. This association is expressed as an odds ratio (OR). A chi-squared test was used to determine if
other quality outcomes were associated with annual colonoscopy volume.
Results: Data was collected on 1060 patients. Mean age was 59.5 (sd12.2) years with 550 females. A total of
13 surgeons were studied, of which 6 performed more than 200 annual colonoscopies over the previous 2
years (high volume group) and 7 performed less than 200 annual colonoscopies over the previous 2 years
(low volume group). While there was a significant difference in the colonoscopy completion rate between
the low volume group and the high volume group (82.2% vs. 91.1%, p\0.001), no difference was noted in
the adenoma detection rate between groups (16.7% vs. 17.7%, p=0.762). The regression model revealed that
colonoscopy completion was associated with an annual colonoscopy volume of greater than 200 (OR=3.17,
p\0.001), an indication of screening or surveillance (OR=1.98, p=0.009), and an ASA score of 1 or 2
(OR=2.29, p=0.020). The adenoma detection rate was associated with older age (OR=1.02, p=0.010) and
male gender (OR=2.04, p\0.001). There was no statistically significant association between annual colonoscopy volume and other quality outcome measures including patient discomfort, perioperative hypoxia,
use of reversal agents, delayed post-polypectomy bleeding, perforation, and unplanned physician contact
within 14 days.
Conclusion: Performing over 200 colonoscopies annually is associated with higher colonoscopy completion
rates but does not appear to be associated with other quality measures.

Background: Biliopancreatic pathology occurs in the Roux-en-Y gastric bypass (RYGB) population.
Anatomical changes after surgery limits endoscopic access to the remnant stomach and thus creates a
challenge in performing endoscopic retrograde cholangiopancreatography (ERCP). Laparoscopic assistedERCP (L-ERCP) gains access via the remnant stomach and thus allows assessment and treatment of stones,
strictures and other sources of biliary pathology. Although this approach has been described for over a
decade, there still remains relatively low experience among surgeons performing it and there is a lack of
agreement as regards the optimal method and technique.
Methods: This was a retrospective case series of consecutive patients undergoing L-ERCP between 2014
and 2015. Our objective was to evaluate the treatment and outcome of biliary disease after L-ERCP. We
evaluated endoscopic/laparoscopic interventions, conversion rate, postprocedure complications, hospital
stay, and procedure time in this study.
All cases were done in a uniform fashion by the same operating surgeon. Keith (straight) needles were used
to mobilize the remnant stomach to the anterior abdominal wall. Then a gastrotomy was made with
electrocautery large enough to introduce a 15mm trocar. Stay sutures on the stomach secured the stomach to
the abdominal wall and an ERCP endoscope was introduced through the port. An intestinal clamp was
placed on the biliopancreatic limb. After the ERCP, the gastrotomy was closed using a laparoscopic stapling
device.
RESULTS: All seven patients with post-RYGB surgery underwent successful L-ERCP for choledocholithiasis and biliary strictures without conversion to open surgery. Endoscopic cannulation through the
papilla with biliary sphincterotomy and a balloon sweep was successfully performed in all cases. The mean
duration of the procedure was 72 minutes and the mean postprocedure hospital stay was 1.1 days. These
results include one patient who had a cholecystectomy performed during the same operation, one operation
with g-tube placement and two procedures which required extensive lysis of adhesions. Two patients were
readmitted for abdominal pain of unclear origin. They did not display any laboratory or radiologic abnormalities and they were both discharged after resolution of their symptoms, neither had required any surgical
or endoscopic reintervention.
Conclusion: L-ERCP using a Keith needle technique for access to the remnant stomach proves to be a safe
and effective method to diagnose and treat biliary disease after RYGB. Our preliminary results show
successful resolution of choledocholithiasis and biliary strictures without major complications.

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P237

Management of Choledocholithiasis with Laparoscopic Surgery

and Endoscopic Retrograde Cholangiopancreatography
in Pregnancy: A Case Series

Minimally-Invasive Creation of Durable Jejuno-Ileal Side-to-Side

Anastomosis Using Self-Assembling Magnets

Christopher F McNicoll, MD, MPH, MS1, Cory G Richardson, MD1,

Lindsay M Wenger, MD1, Matthew S Johnson, MD2, Charles R St.
Hill, MD, MSc, FACS1, Nathan I Ozobia, MD, FACS3, 1Department
of Surgery, University of Nevada School of Medicine, 2Desert
Surgical Associates, Las Vegas, Nevada, 3University Medical Center
of Southern Nevada
The prevalence of gallstones during pregnancy can be as high as 12%, and biliary disease is the second most
common cause of abdominal surgery in pregnancy. Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) have previously been shown to be safe and effective treatments for
complicated biliary disease during pregnancy, as supported by SAGES Guidelines. The authors have
experience performing one-step laparoscopic cholecystectomies with intraoperative ERCP, and we present
the management of choledocholithiasis in two pregnant patients.
Case 1: A 20 year old female, gravida 1, para 0, 8 weeks 1 day pregnant, presented to the emergency
department for the third time with right upper quadrant abdominal pain and tenderness, nausea, and
vomiting for 1 day. An abdominal ultrasound revealed cholelithiasis, choledocholithiasis, and a 9.8 millimeter common bile duct. She had elevated liver enzymes and lipase, no leukocytosis, and total bilirubin 1.2
mg/dL. Her total bilirubin continued to rise to 3.6 mg/dL, and a one-step diagnostic laparoscopy and ERCP
was performed on hospital day 3. Intra-operatively, no gallbladder was found, though the patient had very
dilated common hepatic and common bile ducts. An intra-operative ERCP confirmed the diagnosis of
congenital gallbladder agenesis, and multiple stones were removed from the common bile duct following
sphincterotomy. The patient was discharged on hospital day 5 after an uneventful post-operative course, and
her healthy child was delivered at 34 weeks 0 days.
Case 2: A 27 year old female, gravida 4, para 3, 34 weeks 2 days pregnant, presented to the emergency
department for the seventh time with right upper quadrant abdominal pain and tenderness, nausea, and
vomiting. Her liver enzymes, lipase, and white blood cell count were normal. Abdominal ultrasound
revealed a 12 millimeter common bile duct, and MRCP revealed a 7 millimeter stone in the distal common
bile duct. After discussion with the patient, an ERCP with sphincterotomy and stent placement was performed on hospital day 4, and she was discharged home. She delivered a healthy infant at 39 weeks 1 day.
Two days following delivery, she underwent a one-step laparoscopic cholecystectomy and ERCP for stent
removal. Her post-operative course was uneventful.
Total fluoroscopy times were 6 and 3 seconds, respectively. The surgeon who performs both laparoscopy
and ERCP can potentially reduce both complications and the number of separate procedures that a patient
will undergo for diagnoses such as choledocholithiasis. This is advantageous for all patients, but is especially beneficial for pregnant patients.

Marvin Ryou, MD, Hiroyuki Aihara, MD, PhD, Christopher C

Thompson, MD, MHES, Brigham & Womens Hospital
Introduction: A minimally invasive method of gastrointestinal bypass would be desirable for treatment of
obstruction, obesity, or metabolic syndrome. We have developed a technology based on miniature selfassembling magnets which create large-caliber anastomoses (Incisionless Anastomosis System or IAS).
The IAS magnets can be deployed into a lumen endoscopically or laparoscopically. The IAS magnet selfassembles into an octagonal macro-magnet which then couples with an identical macro-magnet deployed in
an adjacent lumen. The magnets form a large anchored window for immediate bypass if desired. Otherwise,
magnetic compression over several days creates a robust durable anastomosis, and the fused magnets are
naturally expelled.
Aims: To assess (a) procedural characteristics of IAS deployment and (b) long-term integrity and patency of
the resulting jejuno-ileal side-to-side anastomosis
Methods: Endoscopic jejuno-ileal bypass creation using IAS magnets was performed in 8 Yorkshire pigs
survived 2 months. Procedure: Enteroscopy was performed to deploy the jejunal magnet. Given porcine
anatomy (i.e. corkscrew colon and inability to endoscopically reach the ileum) a laparotomy was performed
to identify ileum approximately 50100 cm proximal to the cecum. A 3 mm enterotomy was created through
which the ileal IAS magnet was inserted using a modified laparoscopic delivery tool. The magnets were
manually coupled. Pigs underwent serial endoscopies for anastomosis assessment. Necropsies were performed at 2 months followed by pressure testing of anastomoses and histological analysis.
Results: Jejuno-ileal bypass creation using self-assembling IAS magnets was successful in all 8 pigs
(100%). Patent, leak-free bypasses had formed by post procedure Day 3. All IAS magnets had fused and
were expelled by Day 12. Anastomoses were fully patent at 2 months, with mean maximal diameter of 30
mm. At necropsy, adhesions were minimal. Pressure testing showed anastomotic tissue to be stronger than
native bowel wall in all animals (i.e. leak point was never anastomosis). Histology showed full epithelialization across the anastomosis with no evidence of submucosal fibrosis or inflammation. Video logs were
kept throughout.
Conclusions: Entero-enteral bypass using self-assembling IAS magnets is safe and technically feasible in
the porcine model. IAS magnets can be rapidly delivered endoscopically or through a modified laparoscopic
device. Expulsion of fused magnets avoids retention of prosthetic material. Anastomoses are widely patent
and fully re-epithelialized. 2-month pressure-testing reveals anastomotic tissue to be more robust than native
tissue, while necropsy and histology suggest minimal/absent tissue inflammation. In human anatomy, a
purely endoscopic jejuno-ileal bypass using IAS magnets may be feasible.

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P240

Salvage Endoscopy Utilizing Covered Self Expanding Metal

Stents (CSEMS) in Complicated Duodenal Leaks

Fully Covered Esophageal Stents: Endoscopic Salvage

from a Surgical Perspective

Caolan M Walsh, MD, Ryan P Kelly, BMSc, MD, James Ellsmere,

BSc, MSc, MD, Dalhousie

Ryan P Kelly, BMSc, MD, Caolan Walsh, MD, James Ellsmere, BSc,
MSc, MD, Dalhousie University

Duodenal injuries and subsequent leaks are associated with significant morbidity and
mortality. They are very difficult to manage due to the high volumes of gastric secretions,
bile, and pancreatic enzymes passing through the duodenum. This reducing the rate of
spontaneous closure and subsequent development of chronic abscesses, fistulas, sepsis and
death. Surgical management is also challenging due to the duodenums fixed retroperitoneal
location and intimate anatomic relationship with the biliary and pancreatic ducts. Covered
self expanding metal stents (cSEMS) originally designed for esophageal and colorectal
applications have now been employed in the duodenum. They convey the theoretical
advantage of reducing enteric content through the defect, thus reducing sepsis and promoting healing. There is scarce literature in regards to applicability and overall feasibility
of cSEMS in patients with complicated duodenal leaks. A total of thirteen duodenal SEMS
where inserted in our institution between January 1, 2014 and September 15, 2015. Eight of
these were used for palliation of malignancies causing gastric outlet obstruction and two for
the treatment of benign duodenal strictures.
We observed three cases of duodenal leaks treated with cSEMS. The first patient leaked
after a transduodenal resection of a Gastrointestinal Stromal Tumour (GIST). This patient
required multiple laparotomies, washouts, and drain placements. The patient was left hostile
abdomen and a chronic duodenocutaneous fistula. After placement of a cSEMS the patient
was discharged home after only 5 days. The second patient developed duodenal injury and
leak after multiple retroperitoneal necrosectomies for necrotizing pancreatitis. The cSEMS
remained in good position for 4 weeks before stent erosion and upper gastrointestinal bleed
requiring its removal. Subsequent CT scan did confirmed resolution of the leak. The third
patient developed a duodenal leak after a partial duodenal resection as part of en en bloc
colon, liver, and duodenal resection for metastatic locally advanced colon cancer. A cSEMS
was inserted post operative day two and bilious drain output dropped to scant after only 48
hours. Unfortunately, the patient died shortly thereafter secondary to liver failure. Although
erosion occurred in the second patient, it remained it adequate position long enough to heal
the leak. Salvage endoscopy with cSEMS should be strongly considered in patients with
complicated duodenal leaks as part of traditional the surgical management.

Background: Perforation, fistulization and leak are rare but significant complications of
foregut surgery. These complications carry considerable morbidity and mortality and can be
challenging to manage from a surgical perspective. Endoscopic salvage treatment with fully
covered self-expanding metallic stents (cSEMS) is an evolving area of interest. To date,
data regarding cSEMS has been limited to small observational series. Our aim is to report
our institutional experience with salvage endoscopy for complicated esophageal disease.
Methods: Patients that received cSEMS between July 1, 2014 and September 15, 2015
were included. Patients with duodenal stents were excluded. Primary outcome was inhospital mortality. Secondary outcomes were rate of stent migration, bleeding, and reintervention.
Results: A total of 27 self-expanding stents were placed over the study period. The mean
age was 66. Of these patients, 8 required cSEMS with proximal deployment in the
esophagus. The total number of stent deployments including repositioning and stent
changes was 16. There were no severe adverse events and no in-hospital mortalities. The
overall adverse event rate was 50% (8/16). These were limited to stent migrations (4/16)
and bleeding (4/16). Overall, 12 re-interventions were required for 4/8 patients. One patient
required 6 repeat endoscopic interventions. All re-interventions were limited to endoscopic
stent repositioning. Overall survival at 1 year was 87.5% (7/8) with the only death related to
diffuse metastatic disease after successful placement of 23cm stent from esophagus to
duodenum to exclude a gastric perforation secondary to diffuse large B cell lymphoma.
Conclusions: Endoscopic salvage and prophylactic treatment of benign and malignant
conditions with esophageal cSEMS is an evolving domain of surgical endoscopy. Here we
have reported our institutional outcomes with salvage esophageal cSEMS. Overall survival
after treatment with esophageal cSEMS is excellent for benign disease with all of our
patients alive at follow-up. Adverse events are limited to stent migration, which often
manifest as bleeding. Having a high index of suspicion and a low threshold for repeat
endoscopy can manage the majority of these adverse events. Furthermore, endoscopic
directed proximal fixation can be utilized to reduce stent migration.

P239

P241

Periampullary Duodenal Diverticula (PDD). Does It Really

Matter for Successful ERCP

The Role of Endoscopic Treatments in Early and Late

Anastomotic Complications After Gastric Surgery: A Systematic
Review

Jan M Krzak, MD1, Jonas S Jensen, MD1, Poul B Thorsen, MD,

PhD1, Ada M Krzak2, Lars Stig Jorgensen1, 1Lillebaelt Hospital,
Kolding, Denmark, 2University of Cambridge

Maryam Namazova, MSc, Queen Mary University of London, Barts

and The London School of Medicine and Dentistry

Objectives: The aim of this study was to asses how periampullary duodenal diverticula
affects successful deep common bile duct cannulation (ERCP) in Danish population.
Methods: Prospectively recorded data between January 2006 and August 2015, from a
single referral ERCP Centre in Denmark, were analyzed. Two groups were identified and
compared. Group A with and group B without periampullary duodenal diverticula. Data on
age, gender, successful deep common bile duct cannulation, Needle knife pre-cut rate,
procedure associated complications and duration of procedure were registered. For comparisons, Chi-square test, T-tests (continuous variables distributed normally), and MannWhitney Ranksum tests, (continuous variables not-normally distributed), were used. Statistical significance level was set to 5%. Statistical software package SPSS ver. 23.0 was
used.
Results: A total of 1734 consecutive patients (702 men, and 1032 women) underwent 2834
ERCP procedures. Group A consisted of 172 (9.9%) patients (45% men, 55% women),
group B consisted of 1562 (40% men, 60% women) (P=0.23). Mean age in both groups was
63.4 (13101 years). In group A mean age was statistically significantly higher 72.9 years
compared to 62.4 years in group B (P\0.001). 271 procedures were performed in group A
(ratio 1.550.83 per patient), while 2563 in group B (1.641.18) (P=0.33). Successful deep
common bile duct cannulation was similar in both groups with 88.6% in group A and 90.9%
in group B (P=0.2). Needle knife pre-cut were more frequently used in group B (22.4%),
however not statistically significantly different when compared to group A (16.2%)
(P=0.74). Procedures associated complications such as bleeding requiring simultaneous
endoscopic intervention or perforations were similar in both groups with 9 (3.3%) complications in group A and compared to 67 (2.6%) in group B (P=0.49). Totally, 163 (60.1%)
procedures in group A took less than 30 minutes while only 15 (5.5%) that required more
than 60 minutes compared to 1491 (55.4%) and 131 (5.1%) in group B, respectively.
Detailed results and MR / CT / endoscopy imaging of PPD will be presented.
Conclusions: Prevalence about 10 % of periampullary duodenal diverticula in our
department is similar with other reported series whoever it seems to be clear correlation
between age and prevalence and PDD. Periampullary duodenal diverticula had not affected
successful cannulation neither time of the procedure in our study.

123

Introduction: Early and late anastomotic complications after gastric surgery increase
postoperative morbidity, mortality and duration of hospital stay. The endoscopic treatment
of anastomotic complications is an alternative way to reoperation. The aim of this study is
to evaluate the safety and efficacy of endoscopic treatments in early and late anastomotic
complications after gastric surgery.
Methods: The PubMed, EMBASE, Web of Science and Google Scholar databases were
used to find the articles related to this study. In total 18 articles were selected covering
period from 1994 to 2014. The success rate of endoscopic treatments in early and late
anastomotic complications were calculated and reported.
Results: The study is based on the 342 patients (121 patients for early and 221 patients for
late anastomotic complications) who had anastomotic complications after gastric surgery
and received different endoscopic treatments (stent placement, balloon dilatation, endoclips, fibrin glue and vacuum therapy). The success rate of endoscopic treatment for early
complications is 88% (106 patients out of 121), for late is 97% (214 out of 221) and total is
94% (320 patients out of 342). Stent migration for early complications occurred in 29
patients out of 110 (26%) and for late complications occurred in 7 patients out of 21 (33%).
Complication rate of balloon dilatation occurred in 4% of patients (8 patients out of 200).
Conclusions: The results of the study confirmed that endoscopic treatment in early and late
postoperative anastomotic complications after gastric surgery is very successful alternative
way of treatment to re-operations. It has high rate of success, however there is a risk of after
treatment complications such as stent migrations and perforations.

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P242

P244

Electromagnetic Navigational Bronchoscopy-Guided Diagnosis

of Left Upper Lobe Spiculated Lung Nodule After Prior Right
Upper Lobectomy for Non-Small Cell Lung Cancer

A Combined Rescue Endoscopic Clip and Sems Technique

for Difficult Upper Gastrointestinal Leaks

Eric M Toloza, MD, PhD1, Lila B Cohen, MD2, Joseph R Garrett,

ARNPC, MPH1, Carla C Moodie, PAC1, John N Greene, MD1,
1
Moffitt Cancer Center, 2University of South Florida Morsani College
of Medicine
Introduction: Second primary lung cancer requires accurate diagnosis to avoid unnecessary lung resection
after lobectomy for a first primary non-small cell lung cancer (NSCLC).
Case Presentation: A 61-year-old man, with history of positive purified protein derivative (PPD) skin test
and multiple subcentimeter bilateral upper lobe lung nodules, was found to have a right upper lobe (RUL)
lung nodule that enlarged from 0.6 cm to 1.3 cm over 41/2 months. He underwent robotic-assisted RUL
wedge resection, followed by robotic-assisted completion RUL lobectomy and hilar and mediastinal lymph
node (LN) dissection. Final pathology revealed 1.1-cm poorly-differentiated squamous cell carcinoma, with
2 positive level-11 LNs out of 15 total hilar and mediastinal LNs, T1N1M0, stage 2A. The patient was
offered, but declined, adjuvant chemotherapy and was not candidate for pemetrexed clinical trial due to
alcohol abuse. He underwent lung cancer surveillance by serial computerized tomography (CT) scans every
46 months. Over 31/2 years, a left upper lobe (LUL) spiculated lung nodule became slightly larger and
denser. Rather than surgical resection or transthoracic needle biopsy for diagnosis, the patient underwent
electromagnetic navigational bronchoscopy (ENB) for biopsy of the LUL lung nodule. Via 90-degree Edge
catheter, ENB-guided needle aspiration, brushing, lavage, forceps biopsies revealed no evidence of
malignancy, but did reveal irregular, hyposeptated, ribbon-like hyphae consistent with Zygomycetous fungi.
The patient was prescribed oral voriconazole 200 mg twice daily and resumed lung cancer surveillance with
serial CT scans every 68-months.
Discussion: Unnecessary surgical resection may be avoided by accurate less-invasive diagnostic techniques,
especially after prior pulmonary lobectomy. Transthoracic CT-guided needle aspiration biopsies are associated with risk of pneumothorax averaging 20%, but as high as 54%. Electromagnetic navigational
bronchoscopy-guided biopsies are associated with risk of pneumothorax less than 10%, with diagnostic yield
as high as 80%. We present a case of a patient who had a prior right upper lobectomy for NSCLC and who
has a slowly enlarging contralateral spiculated lung nodule that was suspicious for second primary lung
cancer, but which was diagnosed by ENB to be Zygomycetoma. He is undergoing antifungal therapy and
resumed lung cancer surveillance by serial CT scans.
Conclusion: Electromagnetic navigational bronchoscopy can diagnosis suspicious lung nodules in patients
who had prior pulmonary lobectomy for NSCLC without need for additional surgical resection and with
minimal risk of pneumothorax.

Stylianos Tzedakis, Marius Nedelcu, Antonio Durso, Didier Mutter,

Bernard Dallemagne, Silvana Perretta, Nouvel Hopital Civil
Introduction: Management of leaks following foregut surgery is complex and challenging. Standard
laparoscopic exploration and drainage often precludes early oral intake and discharge from the hospital and
can be associated with significant morbidity. New endoscopic treatments such as covered self-expanding
metal stents (SEMS) and over-the-scope clips (OTC) are proving to be valuable alternative therapeutic
options especially when standard management is not feasible or has failed. Severe local inflammation often
makes primary closure impossible. Likewise, SEMS frequently migrate and require replacement or reoperation. Here, we present a case series where a combined SEMS and over the scope padlock clip (Aponos
) fixation was used to safely and effectively treat post-operative upper GI leaks.
Methods: Between January 2014 and June 2015 a total of 9 patients with post-operative leaks following
UGI surgery were identified. The indications for endoscopic stenting were postoperative leak or fistula (n=
7) and perforation (n=2). Four patients had undergone bariatric surgery (3 conversions from sleeve to
RYGBP, one primary RYGBP), two patients a laparoscopic/thoracoscopic esophagectomy for cancer, one
patient had undergone a laparoscopic enucleation of a giant esophageal leiomyoma and two patients a total
gastrectomy for cancer. All patients had a 22x160mm fully covered SEMS (Hanarostent ) placed endoscopically. A standard sized (11mm) Padlock clip (Aponos Medical ) was used for SEMS fixation. Overall
success in closing leak, migration rate, length of hospital stay, associated morbidity/mortality and number of
stents used were analyzed.
Results: Technical and clinical success rates were 100% with no associated morbidity. Three leaks post total
gastrectomy required a second stent in stent due to upstream persisting leak refluxing from the jejunal
side and one due to migration . All leaks closed in 36 days (range 2990 days). Length of hospital stay was
31 days (range 1690 days). Associated morbidity was negligible. Average number of stents used per patient
was 2. Average number of endoscopic procedures per patient was 4. Removal of both stent and clip was
accomplished successfully using a foreign body grasper with no esophageal injury at clip removal.
Conclusions: Over the scope clips are being used more and more frequently nowadays as an anchoring
system after SEMS placement to prevent migration. Our experience with the Padlock clip supports this
method as a safe and effective treatment.

P243

P245

Evolution of Endoscopic Treatment of Sleeve Gastrectomy Leaks:

From Partially Covered to Long Fully Covered Stents

A Prospective Study of Endoscopic Radio-Frequency NonAblative (Stretta) Therapy for Gastrooesophageal Reflux Disease:
Early UK Experience

Fabio Garofalo, MD, Maxime Noreau-Nguyen, MD, Henri Atlas,

MD, Ronald Denis, MD, Pierre Garneau, MD, Radu Pescarus, MD,
Hopital Sacre-Coeur de Montreal
Introduction: Laparoscopic sleeve gastrectomy (LSG) has become a widely accepted option in the treatment of mordid obesity. Gastric leaks after LSG occur in 07% of the patients, mostly at the
gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support and endoluminal control. Among the various endoscopic treatment options available, stents are the most
common. Recently, long fully covered stents have become available in the treatment of post LSG leaks. Our
hypothesis is that long fully covered stents represent a safe and effective solution for LSG leaks.
Methods and Procedures: A retrospective analysis of our prospectively collected bariatric database was
performed between June 2014 to September 2015. We included all patients treated for leaks after LSG. All
patients underwent a CT abdomen with oral contrast for the initial gastric sleeve leak as well as to document
the fistula closure. Endoscopic treatment included partially covered metallic stent (WallstentTM, Boston
Scientific, Ireland) and long fully covered MegastentTM (Taewoong Medical Industries, South Korea).
Results: During this period, a total of 596 LSG were performed. Overall, 7/596 patients (1.2 %) developed a
gastric leak. One patient was an outside referral. Patients presented on average 28.6 days after the initial
surgery (range, 1275 days). All fistulas were localized at the level of gastro-oesophageal junction. All 8
patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess
drainage. Fistula closure was achieved in 8/8 cases with an average number of 2 endoscopic interventions
(range 14). Average time for closure was 2.1 (range, 13) months and average follow-up after fistula
closure was 5.5 (range, 19) months.
Overall, treatment with partially covered metallic stents failed in 2/5 patients and these patients were
eventually successfully treated with a long fully covered stent. Stent failure was attributed to ongoing leak
around the proximal end of the stent. The initial use of long fully covered stents was successful in 3/3 cases.
No stent migrations or perforations were noted. Only 1/8 patients (12.5%) developed a stent-related esophageal stenosis, treated successfully with serial endoscopic dilatations.
Conclusions: Leaks after sleeve gastrectomy are difficult clinical problems. Several endoscopic procedures
and multimodality treatments are often necessary. Long fully covered stents appear to be a good alternative
to traditional esophageal stents either as primary endoscopic treatment or after failure of other endoscopic
treatments.

Y K S Viswanath, Mr1, Humza Numan, Mr1, Anjan Dhar, Dr2, Sibby

Punnoose, Dr2, 1James Cook University Hopsital, 2Darlington
and Bishop Auckland Hopsitals
Introduction: Radiofrequency non-ablative application (RFA) - STRETTA, is considered appropriate
therapy for patients with gastrooesophageal reflux disease (GORD) (SAGES 2013), producing symptomatic
relief in those patients (UK NICE guidance 2013). This is the first UK study to present our early experience
of patients undergoing RFA for GORD.
Methods and Procedures: A prospective study on all patients who underwent RFA at our institute, October
2014 to August 2015. All patients underwent upper gastrointestinal endoscopy and barium meal as part of
preoperative work up. Data presented as median (interquartile range, IQR).
Results: Over the 10 month period, 19 patients underwent RFA therapy for GORD. The median (IQR) age
was 62 (5265) years with 12/19 (63%) patients were females. All patients received information sheet
explaining the procedures 4 weeks in advance. Four patients have had a previous antireflux surgery. All
patients were dissatisfied with their GORD prior to the RFA with a median (IQR) of pre-RFA heartburn,
dysphagia, and regurgitation scores of 4 (3.54), 2 (04), and 4 (34), respectively, (0=no symptoms,
1=symptoms noticeable but not bothersome, 2= symptoms bothersome but not every day, 3=symptoms
bothersome every day, 4=symptoms affect daily activity, and 5=incapacitating symptoms). Six out of the
nineteen patients had evidence of B2cm hiatus hernia on pre-RFA barium meal. Eight patients underwent
their procedure under general anaesthesia while 11 had conscious sedation.

All patients were treated on a daycase basis. Endoscopic RFA was delivered at all perigastrooesophageal junction 6 levels in all patients with a median (IQR) of 50 (4454), out
of possible 56, treatment points achieving more than 30 seconds cycle. No postoperative
complications were encountered. At a median (IQR) follow up of 4 (26) months, 17/19
(90%) patients were satisfied with the outcome, with the median (IQR) post-RFA heartburn,
dysphagia, and regurgitation scores of 1 (01), 0 (01), and 0 (02), respectively.
Conclusions: Therapeutic endoscopic RFA (STRETTA) is feasible and safe in the treatment of symptomatic
GORD. In short term, it achieves symptomatic relief in the majority of patients. In patients with poor
response to medical therapy, it can be considered as an alternative option to surgery in those who are unfit
for surgical intervention. Long term follow up is essential to appraise the durability of these favourable
outcomes in our population.

123

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P248

Quality Control and Credentialing Guidelines in Colonoscopy: Is

the Endoscopist Success Rate of Caecal Intubation the Only
Factor?

LES-Complex Morphology and Distal Esophageal Reflux Insights

Gained Using HRM

Ahmed Hammad, Milda Jancauskaite, Haitham Aboudeep, Arjit

Mukherjee, Hairmyres Hospital NHS Lanarkshire
Aim: The aim of this study is to assess the colonoscopy results of a singleJoint Advisory
Group (JAG) UK accredited endoscopist and analysis of causes of failure of completion.
Methods: A retrospective analysis of prospective annual colonoscopy data of a designated
accredited colonoscopist (April 20132014). Patient demography, completion rate indicated
by caecal intubation and causes of incomplete cases were retrieved.
This data is compared to the key measurable quality indicator of caecal intubation rate, as
minimum rate greater than 90% have been endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) and the Joint Advisory Group (JAG) UK.
Results: Total number of colonoscopies performed over a calendar year were 740. Caecal
intubation rate(corrected for pathology) was 87.16% (n=645). Failed completion in 12.84%
(n=95), mean age 69 (range1788). 23% (n=21) were due to poor bowel prep, 77%(n=74)
due to looping, discomfort, pain, sigmoid angulations and consent withdrawal.
Conclusion: Colonoscopy remains the gold standard investigation of most colorectal disease. Quality assurance of colonoscopy could be expected to contribute significantly to
improved patient care. Unfortunately, disparity in quality prevails even amongst accredited
dedicated colonoscopists.
Amongst the different confounding factors, poor bowel preparation contributed significantly towards incomplete caecal intubation.
Quality improvement in colonoscopy should focus not only on improving technical skills,
but also on methods to optimise bowel prep and emphasise on stringent patient selection.
Detailed breakdown of confounding factors would probably favour a better quality comparison than an universally defined completion rate.

P247
Unidirectional Barbed Sutures as a Novel Technique
for Laparoscopic Hiatal Hernia Repair
Federico Perez Quirante, MD, Lisandro Montorfano, MD, Nisha
Dhanabalsamy, MD, Rajmohan Rammohan, MD, Alex Ordonez, MD,
Abraham Abdemur, MD, Emanuele Lo Menzo, MD, PhD, FACS,
FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J
Rosenthal, MD, FACS, FASMBS, Cleveland Clinic Florida
Introduction: There is much debate surrounding the method of closure during hiatal hernia
repairs (HHR). Although some evidence exists on the advantage of the use of mesh to
reinforce the hiatal repair, concerns persist on the safety of a foreign body in this location.
This study aims to describe the initial results of a novel surgical technique for primary
hiatal defect closure during HHR using unidirectional barbed suture.
Materials and Methods: Between 2010 and 2015, patients who underwent laparoscopic
hiatal hernia repair were retrospectively reviewed. Patients were assessed with office visits
with detailed follow up. Those who presented with dysphagia after surgery underwent
further studies. Students T test and Chi-Square Test of Independence were used to asses the
statistical significance of our findings.
Results: 362 patients underwent laparoscopic HHR. In 295 patients the hiatal closure was
performed using unidirectional non-absorbable barbed suture alone, while in 67 patients the
hiatal closure was obtained with non-absorbable barbed suture and reinforced with mesh.
Operative time was 87.140.3 min (mean SD) in the non-absorbable barbed suture group
vs. 91.3 30.64 min in the non-absorbable barbed suture plus mesh group (p=0,453). The
average overall follow-up was 8.3911.9 months.
For all procedures, 12% of the operated patients were originally asymptomatic whereas the
rest presented with at least one of the following symptoms: 29% dysphagia, 14% heartburn,
25% regurgitation, 7% night cough, 12% nausea/vomiting, 2% anemia, 40% gerd, 9% chest
pain, 2% hoarseness, 4% burping, 1% hiccups, 5% incarcerated hernia, 5% achalasia, 10%
upper GI bleeding.
Twenty-six patients out of 354 (97.7%) visited the hospital for follow-up within 6 months
after surgery. The non-absorbable barbed suture group compared to the non-absorbable
barbed suture plus mesh group presented the following symptoms: dysphagia, 29 (9.8%) vs.
4 (6.0%) p=0.321, persistent GERD 6 (2.1%) vs. 3 (4,5%) p=0.246, regurgitation 27 (9.1%)
vs. 6 (9.0%) p=0.959 and pseudoachalasia 3 (1.0%) vs. 1 (1.5%) (p=0.736). No clinical
hernia recurrence was noted in either group.
Conclusions: The adoption of continuous unidirectional barbed suture provides a safe,
efficient, and effective alternative to traditional hiatal closure techniques. Our findings
warrant further studies to establish the long-term efficacy of using barbed suture during
laparoscopic HHR.

123

Shunsuke Akimoto, Saurabh Singhal, Sumeet K Mittal, Creighton

University Medical Center
Introduction: Chicago classification has recently added morphological sub-classification
for Lower esophageal sphincter complex. Aim of this study to discuss and hypothesize
esophagogastric junction (EGJ) morphology as assessed by high-resolution manometry
(HRM) and its association with reflux. We assessed esophageal reflux in patients with
Chicago EGJ-Type 3a and 3b.
Methods: After IRB approval, from a prospectively collected HRM database, we identified
patients who underwent pH study between Oct 2011 and Jun 2015 and were diagnosed with
EGJ-Type 3. Chicago EGJ-Type3 is defined as the inter-peak nadir pressure B gastric
pressure and LES-CD separation C2 cm [3a- PIP (pressure inversion point) remains at the
CD level, 3b-PIP remains at the LES level]. We excluded the patients with prior foregut
intervention, esophageal dysmotility, LES-CD [5cm or if 24-hour pH study was done on
acid suppressions. We classified the patients into reflux group [DeMeester score [ 14.72 or
Fraction time pH (\4) [4.2%] and no reflux group.
Results: Fifty patients satisfied study criteria, of which 37 patients (74%) were type 3a.
Abdominal LES length (AL) in reflux group was significantly shorter than no reflux group
(0.1 vs. 0.9 p=0.003). While overall LES length (OL), LES pressure (LESP), LESP integral
(LESPI), Integrated relaxation pressures (IRP) and Distal contractile integral (DCI) were
not significantly different between reflux and no-reflux groups. The pH study was more
commonly positive in LES-CD C3cm than in LES-CD \3 cm (85% vs. 56.7%, p=0.046).
Type 3a patients showed significantly higher values of DeMeester score, Fraction time pH
and the positive pH study than type 3b (DeMeester score: 36.4 vs. 16.1 p=0.005, Fraction
time: 10.1 vs.4.3 p=0.003, positive pH study: 81.1% vs. 30.8% p\0.001). In type 3b, AL in
the reflux group was significantly lower than the no reflux group (0.9 vs. 1.6 p=0.021).
Conclusion: A subset of patients with LES-CD separation maintain a physiological intraabdominal location of EGJ (type 3b) and hence are less likely to have reflux. LES-CD
C3cm seems to discern a hiatus hernia of clinical significance.

P249
Transepithelial Brush Biopsy with Computer-Assisted Analysis
Detects Intestinal Metaplasia and Dysplasia Missed by Forceps
Biopsy Following Ablation of Barretts Esophagus
Jeffrey A Hagen, MD1, Vivek Kaul, MD2, Michael S Smith, MD,
MBA3, 1University of Southern California, 2University of Rochester
School of Medicine, 3Temple University School orf Medicine
Background: Multiple endoscopic methods are utilized to ablate Barretts esophagus (BE)
and esophageal dysplasia (ED). The current standard for post-ablation surveillance involves
four quadrant forceps biopsies (FB) taken throughout the original BE segment. This
technique leaves a significant proportion of mucosa unsampled, decreasing the likelihood of
detecting residual or recurrent intestinal metaplasia (IM) and ED. Wide Area Transepithelial Sampling with Computer-Assisted 3-Dimensional Tissue Analysis (WATS3D) has
been shown to improve detection of both metaplasia and dysplasia when added to FB in
screening/surveillance of BE. Our aim was to further explore the benefit of WATS3D when
used for post-ablation surveillance at multiple centers treating BE.
Methods: Patients undergoing surveillance endoscopy following previous BE ablation
underwent same session FB and WATS3D tissue sampling. Sampling technique, plus the
frequency and location of biopsies, were at the discretion of the endoscopist. All WATS3D
samples were analyzed at a central laboratory using a neural network to highlight potentially abnormal cells in a computer synthesized three dimensional image for review by the
pathologist. FB were read as per each sites standard protocol. Procedures performed
between June 2013 and September 2015 where WATS3D found IM or ED in the postablation setting were identified. Each site provided a de-identified, summarized data set for
these cases, prior to aggregation and analysis.
Results: During the study period, a total of 354 patients underwent 611 procedures where
FB and WATS3D were performed during the same upper endoscopy for post-ablation
surveillance. Most patients were male (75%) with an average age of 65.5 years (2589).
WATS3D identified non-dysplastic IM that was undetected by FB in 27 cases (4%) and ED
not detected by FB in 12 cases (2%). Therefore, the number needed to test (NNT) to
identify an additional case of either IM or ED not detected by FB was 15.7 (611/39). To
identify an additional case of ED, the NNT was 50.9 (611/12). No complications from
WATS3D use were reported.
Conclusions: Following BE ablation, adjunctive use of WATS3D with FB increases the
detection of residual or recurrent IM as well as ED. With a NNT of only 15.7 to identify any
residual or recurrent IM or ED missed by FB, WATS3D provides an effective method to
decrease the sampling error inherent in 4 quadrant FB in this setting.

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P250

P252

Early Experience with Sleeve Gastrectomy for Severe

Gastroparesis

Patient Satisfaction and Symptom Scores Over Time After RedoFundoplication

Shaun C Daly, MD, Mahtab Sohrevardi, MD, Jonathan A Myers, MD,

Minh B Luu, Rush University Medical Center

Shunsuke Akimoto, Saurabh Singhal, Sumeet K Mittal, Creighton

University Medical Center

Introduction: Diabetic gastroparesis is an incurable chronic disease and the goal of treatment is to improve
quality of life for patients. Laparoscopic sleeve gastrectomy to improve symptoms in patients with severe
diabetic gastroparesis has not been described. The faster gastric emptying and better glycemic control
following a sleeve gastrectomy should provide symptomatic improvement with lower morbidity than current
surgical options. Our aim is to assess the safety and efficacy of laparoscopic sleeve gastrectomy as the initial
treatment for the symptoms of severe diabetic gastroparesis.
Methods and Procedures: Inclusion criteria consistent of patients between the ages of 18 and 70 who
presented with a diagnosis of either grade 2 or 3 diabetic gastroparesis as determined by the Gastroparesis
Cardinal Symptom Index (GCSI) The maximum GSCI score is 45 and a score C27 indicate severe disease.
All patients underwent preoperative and postoperative gastric emptying study and a preoperative upper
endoscopy. Preoperative and postoperative GSCI scores were assessed and compared. The laparoscopic
sleeve gastrectomy was performed in a standard fashion but with the use of a 60 French bougie to limit
unwanted weight loss. Patient follow-up was initially at 1 week, then at 1, 3, 6, and 12 months.
Results: Three patients underwent laparoscopic sleeve gastrectomy for severe gastroparesis. The mean
preoperative GSCI score was 39. At one week follow-up, the mean GSCI score decreased to 24 (-38%), a
1-month mean GSCI scores decreased to 20.5 (-47%), and at 6-months the mean GSCI score decreased to 7
(-82%). Each patient had a progressive decrease in mean GSCI scores. The patient who received a
postoperative gastric emptying scan had less retention at 1 hour (80% vs. 50%) and had complete emptying
by 2 hours. Mean follow-up was 10 weeks (range: 124 weeks).
Discussion: Our early experience with laparoscopic sleeve gastrectomy for symptom control in severe
gastroparesis has been promising. In our first three patients we have experienced a decrease in GCSI scores
as early as 1 week postoperative with continued improvement at 6 months of follow-up. In addition, our
patient who received her 6-month repeat gastric emptying study demonstrated normal emptying at 2 hours.
Further patient enrollment and continued follow-up is warranted.

Introduction: As Antireflux surgeries have become common, more patients are presenting with needs for
reoperative interventions. We assessed our patients for short, mid and long term subjective outcomes
following redo fundoplication.
Methods: After IRB approval, from a prospectively managed database, patients who underwent redo
fundoplication between December 2003 and June 2010 were identified. Patients were categorized as Group
A: short term follow-up (12 years), Group B: mid term follow-up 25 years, and Group C: long term
follow-up (C5 years). Subjective symptoms [0(low)3(high)], satisfaction [1(low)10(high)] and use of
medications were compared between the groups. Symptom score of 2 and 3 were taken as severe symptom
and satisfaction score of 810 as excellent satisfaction.
Results: A total of 203 patients underwent redo-anti-reflux surgery during the study period, of which 130
who underwent redo fundoplication form the cohort for this study. Follow-up at short term, mid term and
long term was available for 63 patients, 74 patients and 60 patients respectively. Severe heartburn and
regurgitation were significantly more common in group C than group A (heartburn: 38.3% vs. 12.7% p
\0.001, regurgitation: 20% vs. 6.3% p=0.023). Severe chest pain was significantly more common in group
C than group B (11.7 % vs. 6.3% p=0.043). Group A patients had significantly less requirement for proton
pump inhibitor (14.3% vs. 35.1% vs. 33.3%, p=0.004 for group A vs. group B, p =0.011 for group A vs.
group C). The satisfaction score of C8 was seen in significantly lesser number of patients in group C as
compared with group A (65% vs. 82.3% p=0.025).
Conclusion: The long term follow-up following redo fundoplication is associated with worsening of reflux
symptoms i.e. heartburn and regurgitation. As a result, fewer patients have excellent satisfaction in longterm follow-up.

P251
Linear or Hemi-Double Stapling Technique
Esophagojejunostomy After Laparoscopic Total Gastrectomy
Bandar Ali, MD, Kyo Young Song, PhD, Jin Won Lee, MD, Cho
Park, PhD, Seoul St. Marys hospital, The catholic university
of Korea
Aim: To investigate the feasibility, advantages and disadvantages of two novel types of esophagojejunostomy after laparoscopic total gastrectomy in gastric cancer patients either by linear or hemi-double
stapling technique
Methods: This was a comparison retrospective study of laparoscopy-assisted radical total gastrectomy for
confirmed histopathologically cases of gastric cancer between January 2010 and December 2014. The data
collected from two hospitals. 1st Patients Group from Seoul Incheon St. Marys hospital who underwent
esophagojejunostomy using a Linear Cutter (blue cartilage; Ethicon Endo-Surgery, Cincinnati, Ohio) and
they were 94 patients. While 2nd patients Group data collected from Seoul St. Marys hospital that
underwent esophagojejunostomy using the hemi-double stapling technique (HDST) with anvil head and they
were 58 patients. Both types of esophagojejunostomy were performed under Laparoscopy and Patients
baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative
outcomes and complications were compared between the two groups. The primary endpoint was evaluation
of the surgical outcome of these two types of reconstruction. In addition, complications associated with both
techniques were assessed and compared.
Results: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in 88
(93.61%) patients and conversion needed in 6 (6.38%) patients in the linear group while all 58 (100%)
patients in hemi-double stapling without conversion to laparotomy. There were significant differences in the
patients between the two groups linear vs. circular in clinical ASA 1, 2 grade (P= 0.000), pathological stage
(P=0.002), extent of lymph node dissection D1+b, D2 (P=0.000, P=0.000), combined organ resection
(P=0.000), operative time (280 84.58 min vs. 199.5 37.06 min) P=0.000, Intraoperative blood loss
(197.03244ml vs 81.0344.7 ml) P=0.03, A-loop obstruction (P=0.03), 1st flatus day (3.080.07 vs.
3.340.60) P=0.02, 1st oral diet day (4.08 2.63 vs. 5.223.21) P=0.03, respectively. While age
(59.4411.6 vs. 57.7211.81) P=0.82, BMI (23.412.9 vs. 23.72.6) P=0.62, ASA3 (P=0.48), number of
retrieved lymph node (47.8817.27 vs. 44.1718.40) P=1.2, post op hospital stay (12.0610.11 vs.
12.3813.61) P=0.25, D1 lymph node dissection(P=0.62), D1+a (P=1.0), open conversion (P=0.15),
proximal margin (3.81.2cm vs. 2.70.9cm) P=0.60, distal margin (11.93.6cm vs. 10.02.6cm) P=0.35,
EJ leak (P=0.10), EJ stenosis (P=0.52), EJ fistula (P=0.37), ileus (P=0.6), pneumonia (P=1.0), pleural
effusion (P=1.0), post op bleeding (P=1.00), pancreatitis (P=1.00), intra-abdominal fluid collection (P=1.00),
wound infection (P=0.63) and mortality (P=0.5) were similar between the two groups linear vs. circular
respectively
Conclusion: hemi-double stapling technique with anvil head insertion was seems to be faster and easier
using in compared with linear stapler technique to perform esophagojejunostomy.

P253
Abdominal Cocoon: A Rare Cause of Intestinal Obstruction
Asem Ghasoup, MD, FACS, Ishaq Mudawi, MD, Ayman Al Tahan,
MD, Mohammed Widinly, MD, MRCS, Security Forces Hospital
Makkah
Introduction: Abdominal cocoon syndrome or peritonitis chronica fibrosaincapsulata is a rare condition
that refers to total or partial encapsulation of the small bowel by a fibro-collagenous membrane with local
inflammatory infiltrate leading to acute or chronic bowel obstruction.
Presentation of Case: A 37years old male presented with sub-acute intestinal obstruction. Intra-operatively,
the entire small bowel was found to be encapsulated in a dense fibrous sac. The peritoneal sac was excised,
followed by lysis of the inter-loop adhesions. Postoperative recovery was unremarkable.

Discussion: Most patients with abdominal cocoon syndrome present with features of
recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression
of the intestines within the constricting cocoon. An abdominal mass may also be present
due to an encapsulated cluster of dilated small bowel loops.
Conclusion: Abdominal cocoon is a rare condition causing intestinal obstruction and diagnosis requires a
high index of suspicion because of the nonspecific clinical picture. CT Scan of the abdomen is a useful
radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment of
choice and the outcome is usually satisfactory.
Keywords: Sclerosing encapsulating peritonitis, Subacute intestinal obstruction

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P254

P256

Intrathoracic Omental Herniation After Laparoscopic Sleeve

Gastrectomy and Hiatal Hernia Repair

Omental-Flap Buttressing Decreases Anastomotic Leaks

in Hybrid Miniamlly-Invasive Ivor-Lewis Esophagectomy

Ashish Padnani, MD1, James McGinty, MD1, Darshak Shah2, 1Mount

Sinai St. Lukes, 2Mount Sinai Hospital

Siripong Cheewatanakornkul, MD, UCSF

Overview: Herniation of omentum through esophageal hiatus is uncommon. We present a rare case of omental
herniation through esophageal hiatus after laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair.
Case Presentation: A 27 years old female with no significant past history underwent LSG for morbid obesity.
Intraoperatively she was found to have type 1 sliding hiatal hernia. A primary posterior crural repair with nonabsorbable sutures was performed. Postoperative day (POD) 01 patient had severe nausea and retching. Her vital signs
were stable throughout. An esophagram obtained on POD 1 demonstrated no leak. Postoperative day 2 patient became
tachypneic, tachycardic to 110s and requiring supplemental oxygen maintaining oxygen saturation around 96%.
Pulmonary embolism was suspected. So patient underwent CTA chest which demonstrated large amount of omental
fat herniating into left chest with large left pleural effusion. No pulmonary embolus was identified. Patient was taken
back to OR immediately. Large amount of omentum had herniated through esophageal hiatus anteriorly into the left
chest. This was reduced back to abdominal cavity. About 1 liter of clear fluid was also drained. Mediastinal drain was
placed. On further inspection, posterior repair of the hiatus was intact. Additional anterior sutures were placed to close
the hiatal opening, with non-absorbable sutures. Patient was started on clear liquid diet POD 1, mediastinal tube was
removed and patient was discharged home on POD 3 from second operation.
Conclusion: Omental herniation through esophageal hiatus after posterior repair of hiatal hernia is rare. It can cause
severe respiratory distress and symptoms can mimic pulmonary embolism. Urgent operative repair is indicated with
reduction of omentum and closure of defect.

Background: Despite improved surgical technique and instrumentation, anastomotic leak rate following hybrid
minimally-invasive esophagectomy can be as high as 10%, leading to increased hospital stay and mortality. We sought
to determine if leak rates decreased with the use of an omental-flap to buttress the anastomosis.
Method: A retrospective review was performed of all patients who underwent hybrid (via laparoscopy and minithoracotomy) minimally-invasive Ivor-Lewis esophagectomy at our tertiary academic medical center from 2009 to
2014. Patients were divided into two groups: those who with omental-flap buttressing (omental coverage of intrathoracic staple lines) versus those without. The omental buttress was created by laparoscopically fashioning a long
omental pedicled flap in the abdomen and bringing it up into the thorax. Thirty-day morbidity and mortality, as well as
clinically relevant long-term stricture rate were compared between the two groups.
Results: A total of 119 patients were reviewed during this period. All operations were conducted by the same surgical
team consisting of a thoracic and a general surgeon. Ninety-eight (82%) patients underwent a hybrid minimallyinvasive Ivor-Lewis esophagectomy. Patient demographics did not differ between the two cohorts. Fifty four (55%)
patients did not have the omental-flap buttress while there were 44 (45%) patients had the buttress. Preoperative
chemoradiation, cancer staging, and tumor locations were not significantly different between groups. Four of the five
(80%) reoperations were performed for anastomotic leak, and omental-flap buttressing was associated with fewer
anastomotic leaks and reoperations (Table 1). In up to a two year follow-up, there were no differences in anastomotic
stricture rate. Thirty-day mortality was 1% in the leak group and 0% in the non-leak group.
Conclusion: The use of an omental flap to buttress the esophagogastric anastomosis during minimally-invasive
esophagectomy is technically feasible. This technique decreases the incidence of postoperative anastomotic leak with a
minimal associated risk of long-term stricture development.
Table 1

Clinical outcome of hybrid minimally-invasive esophagectomy

P255
Assessment of Quality of Life Score Sf36 & Disease Specific
Symptoms Following Laparoscopic Nissens Fundoplication
Ajay H Bhandarwar, MS, Samarth S Agarwal, MS, Praveen N
Tungenwar, MS, Amol N Wagh, MS, Saurabh S Gandhi, MS, Chintan
B Patel, MS, Grant Government Medical College & Sir J.J.Group
of Hospitals
Introduction: Aim of this study is to establish responsiveness of quality of life SF-36 score and disease specific scores
in GERD following Laparoscopic Nissens Fundoplication (LNF) with relation to oesophageal manometry and upper
gastrointestinal endoscopy.
GERD is an emerging disease amongst the Asians with prevalence in India ranging from 820%.In India there is no
such study showing effect of LNF on SF -36 score preoperatively and post operatively.
Methods and Procedure: An interventional prospective study was conducted in tertiary referral center in patients
complaining of typical/atypical symptoms of GERD. Total 322 patients underwent LNF from 2008 to 2013. Ten
patients were lost to follow-up and twelve (3.72%) patients were converted to conventional Nissens fundoplication.
Hence total 300 patients were included. Of those 160 patients were male and 140 patients were female with mean age
38.7 ranging from 1860 yrs.
Inclusion Criteria:
1) Patient of age more than 18 years c/o symptoms of reflux and not completely eliminated by PPIs.
2) Diagnosed cases of GERD and hiatal hernia with low PPI compliance.
3) Patients with well documented GERD who desire to stop chronic PPI therapy.
Exclusion Criteria:
Patients with age below 18 years and pregnant patients.
Patients unfit for general anaesthesia.

Patients not willing to participate in the surgery.

After diagnosing, patients underwent LNF and follow up was done at 12 and 24 months after operation.
GERD score was calculated. Higher scores indicated more severe symptoms. Change in scores preoperatively and postoperatively [7 is significant.
SF36 is a well-validated score and measures 8 domains of life. These 8 domains can be summarized as a
physical and mental health component score. A change of more than 5 scale points on any of 8 domains is
clinically significant.
Results:
GERD Symptom SCORE: Paired t test used for calculation. Present study showed change in GERD score between preoperative and post-operative 12 months is 14, as it is more than 7 and hence it is significant. However score was
insignificant between preoperative and postoperative 12 to 24 months.
SF36 SCORE: All dimensions of quality of life score showed significant difference in pre operative and post operative
12 months with p value 0.003.
Conclusion:
In a properly diagnosed PPI respondent patients, LNF has got improvement in GERD score and quality of life in all
dimensions of SF-36 score.
Also LNF is an excellent surgical alternative for GERD patients for increasing LES pressure and decreasing
oesophagitis.

123

P value by Pearsons chi-square test

P257
Partial Fundoplication Results in Excellent Outcomes After
Laparoscopic Paraesophageal Hernia Repair
Ryan D Horsley, DO, Jarrod M Buzalewski, DO, Matthew E Plank,
PAC, Jon D Gabrielsen, MD, David M Parker, MD,
Anthony T Petrick, MD, Geisinger Medical Center
Introduction: The objective of this study was to review the outcomes of patients undergoing laparoscopic paraesophageal hernia repair (LPEHR) with a partial fundoplication. The best operation for paraesophageal (PEH) repair
remains controversial. While reflux is not the most common symptom in PEH patients, there is consensus that
fundoplication is indicated. While the Nissen is most common, the optimal type of fundoplication is not well defined.
Few studies have evaluated partial fundoplication in patients presenting with paraesophageal hernias.
Methods and Procedures: A retrospective review of patients who underwent elective primary LPEHR from May
2012 through June 2014 was performed (n=149). 84 patients were identified in the study group. All underwent LPEHR
with a 270 degree anterior Dor fundoplication. All patients in the study group underwent reinforcement of the crural
repair with biologic mesh.
Results: The mean age of study group was 69 years old. 84% were female. The mean age- adjusted Charleson score
was 4.24. Mean operative time and intraoperative blood loss were 169 minutes and 32.5ml respectively. Collis
Gastroplasty was performed in 19% of patients. One patient (1.2%) required an ICU stay and the overall mean length
of stay was 2.0 days. Of the 84 patients, 13 (15.5%) had a complication within the 30 day postoperative period.
Morbidities were classified as major (Clavien score [ 3) or minor (Clavien score \ 3). There were 2 major complications and 11 minor complications. There were no mortalities at 90 days. The mean length of follow up was 17.9
months. 8 (12.5%) patients had diagnostic evidence of a recurrent hiatal hernia. Only 3 patients (3.6%) had a
symptomatic recurrence with one patient requiring a revision LPEHR. Preoperative dysphagia was present in 49
patients (58.3%), of which, 43 (87.8%) reported improvement post operatively. Of the entire study group, 17 (20.2%)
reported postoperative dysphagia, 8 patients reported dysphagia occurring less than once per week. There was significant improvement in Reflux Symptom Scores (RSI) (17.4 to 3.09; p\0.05) and Health Related Quality of Life
Scores (HRQL) (18.24 to 3.16; p\0.05) at the mean follow up of 17.9 months.
Conclusion: This study confirms previous reports that LPEHR is safe and effective with low mortality, morbidity and
recurrence rates. RSI, HQRL scores and dysphagia were significantly improved postoperatively. Dor Fundoplication
appears to be a good option when tailoring the operative approach for patients with PEH. Further comparison to Nissen
fundoplication is warranted.

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P258

P260

Laparoscopy Heller Miotomy and Partial Fundoplication Is

Insufficient in Patient with Terminal Acalasia. Three Fields
Laparoscopic Esofagectomy for Final Management. Experience
IV Level Center in Colombia

Early Reoperation and Readmission After Foregut Surgery

For PEH And GERD

Eveleyn Dorado, MD, FUNDACION VALLE DEL LILI

Introduction: Achalasia is an esophageal motor disorder characterized by progressive dysphagia. The
laparoscopic Heller myotomy with partial fundoplication is the standard of management in these patients. In
those with large esophageal dilatation it is insufficient, because although cure dysphagia, regurgitation
secondary to ineffective motility and accumulation of food makes the patients quality of life deteriorates
Aim: Show the effectiveness and minimal morbidity of laparoscopic esophagectomy in patients on prior
myotomy and partial fundoplication for achalasia.
Methods: Male patient, 26 y / 0. One year ago consult for dysphagia,his examans: Endoscopy with food
debris, esophageal dilation and suspected achalasia, Manometry confirmed diagnosis. For technical reasons
it is not possible to esophagogram. It is scheduled to Laparoscopy Heller myotomy and Dor fundoplication.
Nutritional profile normal levels. The patient had no postoperative dysphagia, tolerated good soft diet, but at
3 months postoperative regurgitation complains. Esophagogram is performed showing great dilation of the
esophagus with colonic appearance. I decided to symptom management with diet, prokinetics but 12 months
post surgery, patient didnt resist the symptons and we were agree to schedule Minimally invasive
esophagectomy
Results: three fields esophagectomy (prone toracoscopy, laparoscopy and cervicotomy) procedure was
done, operative time was 4 hours, dilation of the esophagus was observed during thoracic dissection. Abdominal time was easy, clearing type Dor fundoplication was not difficult and we could sleeve great
curvature. Cervicotomy and manual traction of esophagus with laparoscopy wiew the mobilization of the
stomach to the chest to avoid twists. Laterolateral cervical anastomosis with staplers. Cervical drainage and
rigth toracostomy. Enteral feeding begins at 6 hours postoperatively. Swallom barium third postoperative
day to check anastomosis and we started oral intake with liquids, next day thoracostomy and cervical
drainage.
Conclusion: Minimante invasive management of achalasia or coversion esophagectomy should be performed by trained surgeons in advanced techniques. It is clear that in patients with achalasia with huge
esophageal dilation the best option is the esophagectomy but in cases that previously made a myotomy with
fundoplication, the procedure can be performed safely with low morbidity and mortality if they are in expert
hands.

Daniel Boyett, MD, Daniela Molena, MD, Miloslawa Stem, MS,

Anne O Lidor, MD, MPH, Johns Hopkins
Introduction: Current literature regarding reoperation and readmission for foregut surgery are limited due
to small sample size and single center study designs. The aim of this study was to identify the incidence and
factors associated with early related reoperation as well as underlying reasons for readmission following
foregut surgery for PEH or GERD.
Methods and Procedures: Patients who underwent foregut surgery for GERD or PEH between 2010 and
2012 were identified from the Truven Health MarketScan database. The primary outcome was related
reoperation and all cause readmission was the secondary outcome. Multivariable logistic regression analysis
was used to identify factors associated with reoperation.
Results: 25,666 patients were identified and 72.9% had their initial surgery performed in an outpatient
setting. Median follow up time was 16.5 months. 3,029 (11.8%) patients were readmitted during the study
period on average 4.2 months postoperatively. Of these readmissions, 11.5% had recurrence of their preoperative condition, 6.07% had digestive system complications, and 3.9% had infectious complications. Of
patients who required surgery during their first readmission (1,579, 6.2%), 18.6% underwent a revisional
procedure. The overall related reoperation rate was 1.8% and was performed at a median of 4.5 months
postoperatively. On adjusted analysis, factors associated with related reoperation included primary surgery
performed in an inpatient setting and advanced age (Table 1).
Conclusion: Early reoperation and readmissions are significant morbidities associated with foregut surgery
for PEH and GERD. This study reveals an association between these significant morbidities and with the
primary procedure being performed in an inpatient setting and advanced patient age.

Table 1

Factors associated with related reoperation following foregut surgery for PEH or GERD

Characteristric

OR (95% CI)

Setting, n (%)
Outpatient

Ref

Inpatient

2.80 (2.243.48)

\0.001

Age, n (%), y
1834

Ref

3544

1.34 (0.911.96)

0.141

4554

1.60 (1.122.30)

0.011

5564

1.57 (1.102.34)

0.013

Procedure type, n (%)

Lap Nissen

Ref

Open Nissen

1.20 (0.861.68)

0.278

Lap PEH

0.85 (0.681.06)

0.140

Open PEH

0.87 (0.591.30)

0.504

P259

P261

Outcomes of Redo Hiatal Hernia Repair: A Single Institution

Experience

Post-Nissen Dysphagia and Bloating Syndrome: Outcomes After

Conversion to Toupet Fundoplication

Nisha Dhanabalsamy, MD, Lisandro Montorfano, MD, Federico

Perez Quirante, MD, Rajmohan Rammohan, MD, Alex Ordonez, MD,
Abhiman Cheeyandira, MD, Emanuele Lo Menzo, MD, PhD, FACS,
FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul
Rosenthal, MD, FACS, FASMBS, Cleveland Clinic Florida

Katrin Schwameis, MD, Joerg Zehetner, MD, Steven R DeMeester,

MD, Nikolai Bildzukewicz, MD, Daniel Oh, MD, Geoffrey Ro, Ross
Katherine, Kulmeet K Sandhu, MD, Namir Katkhouda, MD, Jeffrey
A Hagen, MD, John C Lipham, MD, Keck hospital, USC

Background: Redo laparoscopic repair of hiatal hernias is a technically challenging procedure with
potential significant perioperative morbidity. The aim of this study is to evaluate the safety and efficacy of
laparoscopic re-operative hiatal hernia repair.
Methods: A retrospective review of a prospectively collected database was performed. Al the redo hiatal
hernia repairs were identified. Morbidity, mortality, perioperative and functional outcomes of the second
procedure were analyzed.
Results: Between 2010 and 2015, a total of 74 patients that underwent re-operative laparoscopic hiatal
hernia repair were analyzed. All hiatal hernia repairs were done in a laparoscopic fashion (100%). The
median length of the surgery was 105.3 min (33252 min). The mean blood loss was 54.7 mL. The average
length of stay was 4 days (215 days). The most common complaint before re-operations was dysphagia
(46%) followed by gastro esophageal reflux (39%). The majority of the initial repairs also had a Nissen
fundoplication. (39%). Regarding the technique of the hiatal redo repair there was no difference between
hernia repairs using barbed sutures only and using barbed suture and mesh reinforcement. At the 6 months
follow up visit 5 patients (6.7%) presented de novo GERD, 8 patients (10.8%) dysphagia, 2 patients (2.7%)
recurrent GERD, and 2 patients (2.7%) achalasia. We had no mortality and no clinical evidence of hernia
recurrence in our population.
Conclusions: Re-operative laparoscopic hiatal hernia repair appears to be a safe and effective procedure.
We had no clinical evidence of hernia recurrence and no mortality in our population. The level of patient
satisfaction after the procedure was high in this series. Further studies are needed in order to confirm our
findings.

Introduction: Protracted dysphagia and bloating are potential troublesome complications following Nissen
fundoplication. One treatment option is a redo-fundoplication with conversion to a Toupet (CNT), but
outcomes after this are poorly defined. The aim of this study was to evaluate the effects of CNT on
dysphagia/bloating and GERD symptoms.
Methods: Retrospective data collection and analysis including a standardized foregut questionnaire and
GERD-HRQL were performed for patients who had undergone CNT for the treatment of post-Nissen
dysphagia or bloating syndrome between 2001 and 2014. Patients with hiatal hernia recurrence or slipped/
disrupted Nissen were excluded.
Results: Twenty-five patients (16 males, 9 females) underwent CNT after a mean time of 5.9 years
(0.515.8) at a mean age of 58 (2084) years. Indications for CNT were: A) persistent dysphagia (n=16,
64%), B) combined dysphagia/bloating (n=1, 4%), C) dysphagia/reflux (n=3, 12%) and D) bloating syndrome (n=5, 20%). Ineffective treatment attempts prior to CNT included Botox injections, dilations and
Redo-fundoplication (n=2 vs. n=14 vs. n=1). Manometry and videoesophagram examinations performed
before conversion found esophageal motility abnormalities in 52% (n=13) of patients.
CNT was accomplished laparoscopically in 92% of cases. The mean OR time was 114.4 min (53224). No
mortality or serious complications occurred. Mean follow-up time was 26.7 months (0.8130). Postoperative
relief of the primary symptom occurred in 87%, 100% and 100%/67%, respectively, for dysphagia, bloating
and combined dysphagia/reflux. Further re-interventions were required in four patients. The GERD-HRQL
was obtained in 88% (n=22) of patients post-CNT and showed a mean score of 10.1 (045).
Conclusions: Conversion of Nissen to Toupet fundoplication in the treatment of postoperative dysphagia or
bloating relieved symptoms in 87100% of patients without leading to significant GERD recurrence. Given
the absence of serious complications conversion should be considered earlier in patients with severe ongoing
bloating or dysphagia.

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P264

Laparoscopic Intragastric Resection of Gastric Submucosal

Tumor Using the Combination of Laparoscopy and Oral
Endoscopy

Effects of a New Traction Method for the Upper Esophagus

on Mediastinal Lymph Node Dissection for Esophageal Cancer
During Thoracoscopic Esophagectomy in a Prone Position

Nobumi Tagaya, PhD, Yuhei Hakozaki, MD, Natsuki Yamaguchi,

MD, Mayuka Shimada, MD, Mariko Oya, MD, Yoshikiyo
Matsunaga, MD, Teppei Tatsuoka, MD, Yawara Kubota, Kosuke
Hirano, MD, Asami Suzuki, MD, Kazuyuki Saito, MD, Takashi
Okuyama, PhD, Yoshitake Sugamata, PhD, Masatoshi Oya, PhD,
Department of Surgery, Dokkyo Medical University Koshigaya
Hospital

Soji Ozawa, MD, PhD, FACS, Junya Oguma, MD, PhD, Akihito Kazuno,
MD, Yasushi Yamasaki, MD, Yamato Ninomiya, MD, Department
of Gastroenterological Surgery, Tokai University School of Medicine

Introduction: Recently surgical resection of gastric submucosal tumors (GSTs) has been increased to perform by
laparoscopic approaches. The combination of laparoscope and oral endoscope is mandatory to ensure a feasible and
safe intragastric approach. Here we report our outcomes of laparoscopic intragastric resection for GSTs using
laparoscope and oral endoscope.
Patients and Methods: We performed laparoscopic intragastric resection of GSTs in 20 patients (M:F= 8:12). Their
mean age was 61 years (range: 3475). We selected two approaches: 1) two or three ports were directly inserted into
the stomach (standard approach: SA), or 2) the stomach was directly opened through a 2.5-cm single skin incision at
the umbilicus (umbilical approach: UA). Both approaches were completed under the guidance of oral endoscope and
laparoscope.
Results: Laparoscopic intragastric resection was successful in all patients (SA: 17 patients, UA: 3 ones). The mean
maximum tumor diameter, operation time and blood loss in SA and UA were 26.0 and 33.7 mm, 168 and 80 min and
16 and 8 ml, respectively. One patient in SA required a gastrostomy to remove the tumor. There was one case of
postoperative bleeding. The mean postoperative hospital stay in SA and UA were 7.8 and 7.7 days, respectively. There
were no recurrences during a mean follow-up period of 97.4 months. The use of an oral endoscope revealed the help
for port placement in the stomach, visual assistance during laparoscopic intragastric resection, retrieval of the specimen via the mouth, and a final check for the presence of air leakage or bleeding from after re-inflation of the stomach.
Conclusion: Laparoscopic intragastric surgery using oral endoscopy can be considerably beneficial for patients with
GSTs located in the upper and middle part of the stomach, and when combined with laparoscopic procedures, minimal
surgical invasiveness can be safely achieved.

P263
Laparoscopic Subtotal Y Roux Gastrectomy for Management
of Refractary Gastroparesis. Experience IV Level Clinic
in Colombia
Evelyn Dorado, DR, FUNDACION VALLE DEL LILI
Introduction: Gastroparesis is a rare disease characterized by slow gastric emptying. Patients suffering from vomiting, abdominal postprandial fullnes . The most common cause is diabetes but 30 % can be idiopathic.
Main: To show our experience in the surgical management of patients with gastroparesis refractory to medical
management.
Methods: Descriptive . 3 patients operated in the first five months of 2015, all male, 24, 26 and 65 y / o . All patients
consulted for history of [ 1 year of evolution weight loss about 20 kg, postprandial vomiting, fullness. none had
vitamin deficiency or diabetes. I ordered endoscopy without mass, gastric emptying scintigraphy with solid delay
which confirmed the diagnosis . Treatment was initiated with prokinetic, antiemetic, macrolids and diet indications for
1 month without improvement in symptoms, and loss more weight. They were scheduled for Laparoscopic subtotal Y
Roux gastrectomy
Results: Intraoperative findings :dilated antrum and stomach thicker walls. Patients were hospitalized three day, the
next day after surgery liquid diet was initiated, and was discharged with liquefied and month I advanced to soft diet
.patients did not show any postoperative complication . At 3 months postoperatively patients had scolded between
614 kg with very good tolerance to the diet. No dumping syndrome at moment.
Conclusion: The management of gastroparesis is controversial, medical management in moderate to severe cases is
insufficient and stimulation therapy, jejunostomy or piloroplastia have not proved effective. Subtotal or total gastrectomy has shown good results in the long term regain weight and symptom relief.

Introduction: The effects of a new traction method for the upper esophagus were examined to simplify mediastinal
lymph node dissection (LND) by creating a wider operative space during thoracoscopic esophagectomy for esophageal
cancer, since upper mediastinal LND can be difficult but is oncologically important.
Patients and Methods: We retrospectively reviewed a database of 215 patients with thoracic esophageal cancer who
underwent thoracoscopic esophagectomy in a prone position between September 2009 and August 2015. We
attempted to improve the upper mediastinal LND method as follows: method A (no traction of the upper esophagus)
during the first term, method B (esophageal traction with one thread) during the second term, and method C (esophageal traction with two tapes) during the third term. We then compared the number of dissected lymph nodes, the
operative time, the blood loss, and the rate of recurrent laryngeal nerve (RLN) palsy among these three methods.
Results: We selected 166 patients who were pathologically confirmed to have both more than one lymph node around the
right RLN and more than one lymph node around the left RLN (method A, 33 patients; B, 83 patients; C, 50 patients). The
mean age was 66 years, and there were 144 male and 22 female patients. The mean number of dissected lymph nodes
around the right RLN for method C (3.7) was greater than those for methods A and B (2.3, 2.7) (ANOVA, P = 0.001;
Tukey, P = 0.004). The number around the left RLN for method C (7.6) was greater than those for methods A and B (4.1,
5.4) (P \ 0.001, P = 0.002). The mean number in the upper mediastinum for method C (13.7) was greater than those for
methods A and B (7.9, 10.1) (P\0.001, P\0.001). The mean thoracoscopic time for method C (259 min) was only longer
than that for method B (226 min) (Grames-Howell, P = 0.03). No differences in the mean thoracoscopic blood loss were
observed among three methods. No differences in the rate of RLNP were observed among methods A (24%), B (35%), and
C (38%) (Chi-square, P = 0.551). No operative deaths occurred in this series.
Conclusions: This new traction method for the upper esophagus using two tapes was effective for thoracoscopic
surgery for esophageal cancer in terms of the number of dissected lymph nodes and the rate of RLNP. Further
reductions in the operative time will be necessary.

P265
Thermal Enterography Detects Esophageal Injury in Ex-Vivo
Model
R Gregory Conway, MD1, Benjamin Baker2, Jonathan P Pearl, MD2,
1
University of Maryland Medical System, 2University of Maryland
School of Medicine
Introduction: Laparoscopic foregut surgery is commonly performed for the treatment of foregut pathology, including
gastroesophageal reflux, achalasia, as well as paraesophageal and hiatal hernias. Often, these cases are elective. One
potential major complication of this technique is inadvertent enterotomy, which occurs with a frequency of approximately 1%. In some series, up to 16% of these perforations are discovered postoperatively, which leads to additional
interventions, increased length of stay, and significantly higher morbidity. We describe a technique for intraoperative
detection of foregut enterotomy using a custom thermal imaging camera.
Methods and Procedures: A custom thermal laparoscope prototype was developed as a modification to a commercially
available FLIR Lepton thermal camera. Porcine esophagus and stomach were used for experimentation after being warmed
to room temperature. The thermal camera was mounted 20-cm from the specimen. Ice water was used as a contrast agent.
Using a Toomey syringe, 60-cc of ice-water was injected through a 22 French Foley catheter which was secured in the
proximal esophagus. Control images were obtained in the native, undamaged foregut. A scalpel was used to create a small
enterotomy in the distal esophagus and ice-water injection was repeated during image acquisition.
Results: Thermal imaging was capable of defining foregut anatomy (Fig. 1). In the native, undamaged foregut, the contrast
stream was not visible in the enteral lumen. After creation of a 2-mm enterotomy in the distal esophagus, the ice-water injection
was repeated. The thermal imaging camera clearly demonstrates a stream of contrast leaking from the enterotomy (Fig. 2).
Conclusions: Thermal enterography is capable of detecting an enterotomy using a universally available and low-cost contrast
agent. This technique can be performed intraoperatively, during both laparoscopic and open procedures. This affords the surgeon
an opportunity to repair the potentially missed enterotomy during the index operation, reducing the likelihood for a morbid and
costly complication. Future work involves in vivo experimentation and miniaturization of the prototype thermal imaging camera.

Fig. 1

Thermal image of native, undamaged foregut. Straight arrow Esophagus. Curved arrow Stomach

Fig. 2 Thermal image of damaged foregut. Straight arrow Esophagus. Curved arrow Stomach. Chevron
Constrast Extravasation

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P266

P268

Gastric Submucosal Tumor Successfully Treated by Reduced

Port Surgery: Report of Two Cases

Multimodal Approach to Early Esophageal Cancer

Kazuto Tsuboi, MD1, Yuya Nyumura, MD1, Masashi Tsunematsu,

MD1, Yasuhiro Takeda, MD1, Yu Kumagai, MD1, Hiroaki Kitamura,
MD1, Takayuki Dotai, MD1, Kazuhisa Yoshimoto, MD1, Tetsuya
Kajimoto, MD1, Fumiaki Yano, MD, FACS2, Nobuo Omura, MD3,
Hideyuki Kashiwagi, MD1, Katsuhiko Yanaga, MD, FACS2, 1Fuji
City General Hospital, 2The Jikei University School of Medicine,
3
Nishisaitama-Chuo National Hospital
Introduction: Laparoscopic surgery is now becoming the standard approach to surgical treatment of gastric
submucosal tumor in developed countries. Recently, reduced port surgery is increasingly performed for such
a condition in selected facilities. We experienced two cases of gastric submucosal tumor with exophytic
growth which were were successfully treated by laparoscopic reduced port surgery.
Cases: The first patient was a 70-year-old male who was referred to our hospital for gastrointestinal stromal
tumor of the stomach. The tumor was 60 mm in diameter and was located in the posterior wall of the midbody of the stomach. The second patient was a 43-year-old female who was referred to our hospital for
gastric schwannoma. The tumor was 40 mm in diameter and was bleeding from a delle. These two tumors
were located in the posterior wall close to greater curvature of the stomach, which were far from the vagus
nerve. We planned to perform reduced port surgery for both cases. The patients were placed in a supine
position and the operator stood between the legs of the patient. At first, EZ access port was inserted at the
navel and three 5-mm trocars were placed. Additionally, one 5-mm trocar was placed under the costal arch
along the left midclavicular line. After exposing the base of the tumor circumferentially, we used an Endoloop in order to grasp and pull the neck of the tumor. Then a part of the stomach was excised encompassing the tumor with an Endo-GIA. The operation time was 52 and 43 minutes, respectively and
intraoperative blood loss was minimal in each patient. The postoperative course of the two patients were
uneventful and they remain free of recurrence.
Conclusion: Exophytic submucosal tumor of the stomach is a good indication for reduced port surgery.

Juan M Riganti, Md, Franco F Ciotola, Md, Mauricio G Ramirez, Md,

Cecilia Zubieta, Md, Adolfo Badaloni, Md, Fabio Nachman, Md,
Alejandro Nieponice, Md, PhD, Esophageal Institute, Favaloro
University Hospital
Introduction: Early detection of esophageal cancer is increasing within surveillance programs. Novel
endoscopic therapies, such as endoscopic mucosal resection (EMR), submucosal dissection (ESD) or
radiofrequency ablation (RFA) have led to a new paradigm of organ preservation in many of these patients.
However, surgery should be the first choice when oncological risk is not negligible. Those patients can
benefit from minimally invasive procedures. Providing endoscopic and minimally invasive therapies as a
single team in a joint effort between the gastroenterologists and surgeons allows the window of opportunity
not to be missed. We present our experience using a multimodal approach in a University Hospital setting.
Methods and Procedures: From 2012 2015 a total of 28 patients (median age 64,5 years) with early
esophageal cancer (t1a,b) or downstaged to complete remission were treated. 16 patients received endoscopic treatment while the remaining 12 underwent surgery using minimally invasive esophagectomy.
Patients with endoscopic therapy were treated with EMR (N=11),or ESD (N=4), and subsequent RFA
(N=11), when needed. Median follow-up was 21,5 months. Endpoints included R0 resection, number of
treatment sessions to achieve R0.
Results: Complete resection R0 was achieved in 16/17 cases (94%) for the endoscopic group and 12/12
cases (100%) in the surgery group. The average number of treatment sessions for endoscopic therapies was
2.25. 5 patients in the surgical group had complications including surgical site infections (n=2), pneumonia
(n=2), anastomotic stricture requiring dilation (n=1), and pyloric syndrome (n=1) which required conversion
to Roux-Y. The main complications in patients undergoing endoscopic treatment were stricture requiring
dilation (n=2), and bleeding of the resection site (n=1) requiring transfusion. There was no mortality in any
of the groups. One patient in the endoscopic group was found to have a recurrence during surveillance and
was successfully treated with surgery.
Conclusion: Endoscopic therapies allow organ preservation with equivalent outcomes and less morbidity
than surgical treatment under a strict surveillance protocol. Minimally invasive surgery is a safer option
when warranted by oncological stage and has less morbidity and mortality rates than open surgery. The
balance between endoscopic and surgical resection is still matter of debate and seems to be strongly
influenced by the working environment. Embracing all therapies within the same multimodal professional
team eliminates the bias of expertise and availability that is usually faced by surgeons or gastroenterologists
when working on their own and allows for better outcomes.

P267

P269

Management of Chylothorax After Minimally Invasive

Esophagectomy: Description of Case Series

Laparoscopic Nissen Fundoplication Versus Magnetic

Gastroesophageal Sphincter Augmentation: Comparison
of Patient Reported Outcomes and Costs

Stylianos Tzedakis, Silvana Perretta, Marius Nedelcu, Didier Mutter,

Emanuele Boatta, Bernard Dallemagne, Nouvel Hopital Civil
Introduction: Chylothorax after esophagectomy remains an uncommon but challenging clinical problem
with an incidence of 0.4%4% and a mortality rate reaching 3050% if untreated. Chylothorax may lead to
acute cardiorespiratory distress via mechanical compression or long-term immunodepression and malnutrition due to chronic depletion of chyle. Among others, identified causes for thoracic duct injury include
anatomical variants of the thoracic duct and low BMI (\30kg/m2). Treatment of chylous leaks remains
controversial even today and is based on conservative, radiological and surgical techniques.
Here we show the management of post-esophagectomy chylothorax in three patients while providing an
overview of the different minimal invasive options available and indications for surgical intervention.
Methods: Between Mars 2010 and Mars 2015, 3 patients with post-operative chylous leaks following
minimally invasive esophagectomy (MIE) were identified. The first patient (48yo woman) developed an
early chylothorax at postoperative day (POD) 2 after MIE for a recurrent caustic esophageal stricture. Due to
high flow rate after conservative treatment a ligature of the thoracic duct was performed under thoracoscopy
at POD7. The second patient (60yo man) was admitted to the emergency room for respiratory distress at
POD26 after MIE for an ypT3N1MO adenocarcinoma of the distal esophagus. Similarly, after diagnosing
chylothorax, aggressive conservative treatment failed, leading to reoperation and ligation under thoracoscopy. The third patient (60yo woman) presented a chylothorax at POD7 after MIE procedure for a lower
esophageal ypT1N0M0 squamous cell carcinoma. Initial conservative treatment and thoracoscopic ligation
of the thoracic duct at POD14 failed. For this reason a radiological upstream embolization of the thoracic
duct was attempted.
Results: All but one patient were successfully managed with surgical ligation of thoracic duct after after
failure of conservative management and persistence of high chyle flow rate ([10ml/kg/day). In one patient
radiologic embolization with glue was successful and demonstrated an anatomical variation of the thoracic
duct course and of its tributaries which could explain both the injury during MIE and the unsuccessful
surgical attempt to ligate it.
Conclusions: Postoperative chylothorax is associated with significant postoperative morbidity and mortality. There is no generally accepted consensus on the indication and timing of surgical intervention. When
non-operative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus
should be attempted. Although its exact role remains to be determined, radiographic embolization offers an
attractive minimally invasive alternative to surgery.

Boris Zevin, MD, PhD, Jeffrey W Hazey, MD, Kyle A Perry, MD,
The Ohio State University
Introduction: Magnetic sphincter augmentation with the LINX device is a novel surgical approach for
lower esophageal sphincter dysfunction. The objective of this study was to compare patient reported outcomes and in-hospital costs for laparoscopic Nissen fundoplication (LNF) and LINX procedure in patients
with symptomatic gastroesophageal reflux disease (GERD).
Methods: A retrospective case-control study was performed for consecutive patients undergoing LNF and
LINX procedure between March 2013 and July 2015 at a tertiary academic center. Pre and post-operative
patient reported outcomes for GERD symptoms and quality of life were assessed with Gastroesophageal
Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire and GERD symptom score
(GERSS). The total, direct and indirect in-hospital cost per LNF case and LINX case were obtained.
Parametric data were analyzed using t-test and non-parametric data were analyzed using Mann-Whitney U
test. Significance was set to p \ 0.05.
Results: Forty-five patients underwent LNF and 25 patients underwent LINX procedure. Median duration of
follow-up was 5 (48) weeks. Age, gender, ASA and pre-operative DeMeester scores were equivalent
between the groups. Pre-operatively, patients undergoing LNF had a higher BMI (30.1 4.8 vs 26.8 4.9
kg/m2, p\0.01) and more severe symptoms of GERD (GERD-HRQL: 33.5 9.1 vs 26.0 9.3, p\0.01 and
GERSS: 44.3 15.7 vs 34.5 16.3, p\0.01) than LINX patients. The duration of surgery (90.2 25.1 vs
62.6 21.9 min, p\0.01) and hospital stay (1.2 0.6 vs 0.6 0.6 days, p\0.01) were greater for LNF
versus LINX. Significant improvement in GERD symptoms was seen after LNF (GERD-HRQL: 33.5 9.1
vs 8.9 11.7, p\0.01 and GERSS: 44.3 15.7 vs 13.9 18.0, p\0.01) and LINX (GERD-HRQL: 26.0
9.3 vs 11.7 12.7, p\0.01 and GERSS: 34.5 16.3 vs 17.6 18.1, p\0.01). Post-operatively, resolution of
GERD symptoms was seen in patients undergoing LNF and LINX (GERD-HRQL: 8.9 11.7 vs 11.7
12.7, p=0.34 and GERSS: 13.9 18.0 vs 17.6 18.1, p=0.37). The total in-hospital cost was $7,336 USD
($3,279 direct cost, $4,056 indirect cost) per LNF case and $13,011 USD ($8,524 direct cost, $4,488 indirect
cost) per LINX case.
Conclusion: Resolution of GERD symptoms was seen after laparoscopic Nissen fundoplication and
laparoscopic magnetic sphincter augmentation with the LINX device; however, the LINX procedure was
more expensive. Studies with long-term follow-up are needed to determine the cost effectiveness of the
LINX procedure.

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P270

P272

Study of the Usefulness of a Novel Gauze-Rolled Liver Retractor

in Laparoscopic Surgery

Laparoscopic and Open Duodenojejunostomy for SMA

Syndrome: A Single-Institution Case Series

Nobuyuki Sakurazawa, MD1, Masao Miyashita, MD1, Sigeki

Yokomuro, MD1, Satoshi Matsumoto, MD1, Akihisa Matsuda, MD1,
Kazuya Yamahatsu, MD1, Junichiro Harada, Dr1, Tomohiko Yasuda,
Dr1, Eiji Uchida, MD2, 1Nippon Medical School Chiba Hokusou
Hospital, 2Nippon Medical School Hospital

B Padilla-Jones, N Sutherland, MD, Ed Auyang, MD, University

of New Mexico

Introduction: Various techniques are used for retraction of the liver during laparoscopic surgery. Herein,
we report the use of a novel retractor with the metal end covered with gauze so that the liver can be
maintained in position via the friction force generated between the retractor surface and a minimal degree of
liver damage is induced.
Methods: For smooth passage through a 12-mm port, the retractor has a 5-cm long and 1-cm wide tip with
two holes to fix the gauze. The angle of the tip can be adjusted from horizontal to vertical. In addition, the
shaft has a small diameter (2.4 mm), resulting in the formation of only a small abdominal wall scar. Thirteen
laparoscopic assisted distal gastrectomy (LADG) patients (10 males and 3 females) who underwent surgery
using our retractor from October 2014 onwards (Group A) and 21 patients (12 males and 9 females) who
underwent surgery using a Nathanson retractor from 2014 onwards (Group B) were compared in respect of
the operation time, amount of bleeding, postoperative liver function and postoperative length of hospital stay
(since postoperative severe liver dysfunction has occurred with the use of the Nathanson retractor in our
hospital, the position of the retractor is changed every 15 minutes for relief of congestion; however, no
intraoperative change of the retractor position for congestion relief is required with our gauze-rolled
retractor).
Results: There were no differences in the demographic characteristics between the two groups. In groups A
and B, the operation times were 263.4 and 255.1 minutes (P = 0.62) and the amounts of bleeding were 109.6
and 74.8 g (P = 0.68), respectively. In regard to the postoperative liver function, the GOT values were 79.7
and 55.7 IU/L (P=0.12), the GPT values were 83.2 and 61.9 IU/L (P=0.29), the LDH value were 210.9 and
205.8 U/L (P=0.77) and the total bilirubin values were 0.98 and 1.04 mg/dL (P=0.71) respectively. The
postoperative lengths of hospital stay were 12.2 and 13.6 days in Groups A and B, respectively (P = 0.25).
Thus, there were no significant differences in the examined parameters between the two groups.
Conclusions: The results suggest that use of the gauze-rolled liver retractor during laparoscopic surgery is
useful, especially as it necessitates no position change for safety and congestion relief and leaves only a
small scar on the abdominal wall.

Introduction: Superior mesenteric artery (SMA) syndrome is a rare condition with less than 500 cases
reported in the literature. Duodenal obstruction occurs when the overlying SMA angulates after rapid weight
loss. Surgical treatment is usually reserved for patients who do not respond to nutritional supplementation
for attempts at weight gain. In our institution we have begun to explore the use of laparoscopic duodenojejunostomy in select patients.
Methods: A retrospective review was conducted for patients undergoing surgical treatment for SMA
syndrome between November 2014July 2015. Five patients were identified. Presentation, patient demographics, intraoperative and post-operative outcomes were extracted.
Results: The most common presenting symptoms were weight loss, nausea, and vomiting. One patient
presented with abdominal pain and one patient with bloating. Patient ages ranged from 2078 years.
Weights ranged from 46.157.5kg. All patients underwent advanced imaging to confirm the diagnosis. Two
patients underwent laparoscopic duodenojejunostomy (LDJ) and 3 patients underwent open duodenojejunostomy (ODJ). The mean duration for LDJ was 222 minutes vs. 214 minutes for ODJ. Mean length of
hospital stay was 10 days for LDJ and 9 days for ODJ. One of the LDJ patients required exploratory
laparotomy for suspected leak on post-op upper GI series, but exploration revealed no leak and was found to
be falsely positive. All patients reported resolution of presenting symptoms at their post-operative clinic
visit.

Conclusion: SMA syndrome is a rare clinical entity. Laparoscopic duodenojejunostomy is a viable option
for treatment of SMA syndrome. In our institutional series, intraoperative and peri-operative outcomes were
equivalent between laparoscopic and open approaches. Additional studies are required to determine
selection of LDJ vs. ODJ.

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P273

Endoflip Correlates with Postoperative Dysphagia and Reflux

After Fundoplication

Gastric Outlet Obstruction and Secondary Small Bowel

Obstruction Secondary toMigrating Tumor???

Yalini Vigneswaran, MD1, Matthew Gitelis2, Lava Patel, MD2,

Brittany Lapin, MPH2, Joann Carbray2, Michael B Ujiki, MD2,
1
University of Chicago, 2NorthShore University HealthSystem

Ariel Shuchleib, MD, Omar Bellorin, MD, Saurabh Sharma, MD,

Litong Du, New York Presbyterian Queens

Introduction: FLIP is being more commonly used intraoperatively to adequately evaluate the GEJ as a
smart bougie. However it is unclear how these measurements correlate with postoperative function,
symptoms and patient related outcomes.
Methods: After 2011 a prospective cohort study of patients presenting to a single surgeon for surgical
treatment of gastroesophageal junction pathology were evaluated intraoperatively with the FLIP device.
These patients included achalasia, GERD and paraesophageal hernias. Beginning in 2011 diameter was
measured pre and postoperatively and in 2014 distensibility was also recorded. All patients were evaluated
pre and postoperatively with health related outcome scores. Based on postoperative 3 week health reported
outcomes patients were designated as clinical success or clinical faliures. Clinical success was classified as
Eckardt equal to zero, RSI B15, Dysphagia Score B2 or GERD B10. Differences were analyzed using
paired t-test, Mann-Whitney U test, and ANOVA.
Results: Preoperative mean FLIP diameters were significantly different between pathologies (p\0.02):
achalasia (6.18 mm+/- 1.73, n=30) and GERD/paraesophageal hernia (9.63+/-6.06, n=36). Distensibility
was also significantly different: achalasia (1.25mm2/mmHg +/- 1.0, n=20) and GERD/paraesophageal
hernia (4.29 +/-8.29, n=31). Diameter and distensibility improved after treatment in all cohorts.
Postoperatively, GERD and paraesophageal hernia repairs that had significant dysphagia (Dysphagia score
[2, n=12) were 3.0 times more likely to have an intraoperative pressure [30mmHg and always had a
diameter \10mm (p\0.05). Distensibility measured after treatment did not seem to correlate to symptoms.
One patient who required dilation postoperatively due to significant dysphagia had an intraoperative
diameter 8.6mm and pressure 34 mmHg. One third of patients that had significant reflux (RSI[15) had a
pressure \20mmHg as compared to 0% of patients who did not have significant symptoms. Significant
dysphagia after myotomy for achalasia (n=8) did not seem to correlate with intraopertive measurements.
However achalasia patients with significant GERD postoperatively were 5.7 times more likely to have
diameter [10mm (p=0.02). Other measurements did not appear to correlate with symptoms.
Conclusion: The FLIP device may have a role in helping make intraoperative decisions to avoid poor health
related outcomes postoperatively. Patients with significant postoperative symptoms of dysphagia or reflux
were more likely to have specific geometery as measured by FLIP at the time of the procedure. Larger
population studies are necessary to clearly define the goal measurements required before leaving the
operating room for good clinical outcomes in these patients.

123

Introduction: Gastric outlet obstruction (GOO) is a blockage in the outflow of the stomach that is characterized by abdominal pain and postprandial emesis of undigested food. It is secondary to a mass, scar
tissue or an inflammatory process. Historically the most common cause was peptic ulcer disease but an
unusual etiology today due to usage of proton pump inhibitors and H2 blockers.
Small bowel obstruction (SBO) is the interruption of the flow of the intestinal content for which the etiology
is variable, and the most common cause is adhesions secondary to previous surgeries; but masses, hernias,
and intussusception among others are also common causes of SBO.
Case Report: 81 year old Chinese female presented with abdominal pain and emesis for two days. Blood
work was unremarkable and she underwent a CT scan that showed a distended stomach and duodenum, with
a mass in the third portion of the duodenum. The stomach was decompressed with nasogastric tube. She had
an upper endoscopy that was unremarkable. Due to lack of resolution of symptoms an upper GI series was
done and it showed a 4x3 cm mass that had migrated to the mid ileum obstructing the small bowel.
She was then taken to the OR for a diagnostic laparoscopy during which the mass was seen, an enterotomy
was performed in the mid ileum, a phytobezoar was extracted and the bowel was closed in a transverse
fashion in 2 layers.
Upon further questioning, the patient endorsed that she ate dried seeds on a regular basis that she swallowed
without chewing them.
Discussion: Any pathology that mechanically obstructs the emptying of the stomach produces gastric outlet
obstruction. The etiology can be a benign or malignant process. Before the era of PPIs and H2 blockers the
most common etiology was peptic ulcer disease, however, today over 50% of the cases are attributable to
malignancy. Another less common etiology is a bezoar. A bezoar is a concretion of non-digestible material
in the gastrointestinal tract that can present with a variety of clinical manifestations, like: gastritis, gastric
ulcers, perforation, or small bowel obstruction and GOO as in this case.
There are multiple options for management in these patients: enzymatic treatment with Papain or Cellulase
to try to dissolve the bezoar, endoscopic fragmentation and removal, less orthodox alternatives with
questionable efficacy like cola, and surgery.

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P274

P276

Gastric Schwannoma - A Rare Cause of Dyspepsia

1

Shadi Al-Bahri, MD , Esther Cha, MD , Patrick Domkowski, MD,

PhD, FACS3, Jason Radecke, MD, FACS, FAMBS3, 1University
of South Florida, 2MedStar Union Memorial Hospital, 3Riverside
Surgical and Weight Loss Center

Risk Factors of the Recurrence After Laparoscopic Gastrectomy

for Gastric Cancer
Hideya Kashihara, Mitsuo Shimada, Kozo Yoshikawa, Jun
Higashijima, Toshihiro Nakao, Masaaki Nishi, Chie Takasu, The
department of surgery, the university of Tokushima

Introduction: Gastrointestinal schwannomas are rare benign neoplasms that are distinctively unique when compared to soft-tissue and central nervous system mesenchymal
neoplasms. We present a case of a gastric schwannoma causing severe reflux treated successfully by a laparoscopic wedge gastrectomy.
Case Presentation: 42 year old male with long standing reflux was found to have a 5 cm
mass along the lesser curvature of the stomach. A laparoscopic wedge resection was performed. Pathology showed a gastric schwannoma. He was discharged home after an
uncomplicated hospital course.
Discussion: Schwannomas are rare tumors arising from Schwann cells that cover peripheral
nerves. Rarely, schwannomas can present in the gastrointestinal tract with the stomach as
the most commonly affected organ. Gastric schwannoma represent only 0.2% of all gastric
tumors and 4% of all benign gastric neoplasms. Colonic and retroperitoneal schwannomas
are extremely rare. Schwannomas are slow growing and usually asymptomatic but can
present with a variety of symptoms, such as abdominal pain, dyspepsia, gastrointestinal
bleeding, and an abdominal mass. They can also present as a gastroduodenal intussusception, perforation leading to abscess formation or a unilateral pleural effusion. Accurate
pre-operative diagnosis of gastrointestinal schwannomas is often difficult due to the rarity
of this condition. Computed tomography (CT) scanning typically demonstrate well-demarcated and homogenous enhancement features. Endoscopic ultrasound (EUS) can be
helpful for EUS guided fine-needle aspiration or biopsy of submucosal tumors. Gastric
schwannomas are often misdiagnosed as malignant gastrointestinal stromal tumors (GIST)
following EGD, EUS and PET/CT (Positron emission tomographic/computed tomographic)
imaging. Definitive diagnosis can only be made by surgical resection followed by immunohistochemical staining.
Conclusion: Schwannomas are rarely found in the gastrointestinal tract and can present
wtih a variety of symptoms such as dyspepsia or abdominal pain. Preoperative diagnosis is
often difficult and challenging to distinguish from other mesenchymal tumors. Definitive
treatment includes complete surgical excision with negative margins. The outcome after
surgery is excellent as these neoplasms are generally benign in nature.

Background: Laparoscopic gastrectomy (LG) have shown good outcomes in early gastric
cancer (GC). However, recurrent cases after LG are observed. The aim of this study is to
analyze risk factors of recurrence after LG.
Methods: Study1: 431 patients with GC who underwent LG were enrolled (LG143,
OG288). Propensity scores were estimated using logistic regression model with the
dependent variables as odds of undergoing laparoscopic surgery and the independent
variables as pathologic T, N, Stage and lymph node dissection. Disease-free survival (DFS)
according to clinicopathological factors in LG and OG group were estimated by using the
Kaplan-Meier method.
Study2: The risk factors of recurrence after LG were investigated by multivariate analysis.
Results: Study1: 143 patients who were performed LG and 288 patients who were performed OG were balanced to 57 pairs. The 5-year DFS rate in LG and OG were 91.4% and
95.8%, respectively (n.s.). In Stage IA, IB, IIA and IIB, 5-year DFS in LG and OG showed
no significant differences.
Study2: In LG group (n=143), six recurrent cases were observed (Liver: 2, Peritoneum: 4).
There were neither lymph node nor port-site recurrence after LG. In univariate analysis (5year DFS), fN (+), ly (+) and v (+) were the prognostic factors. The independent risk factor
for recurrence in LG was fN(+).
Conclusion: DFS in LG is comparable to that in OG. fN(+) is independent risk factor for
recurrence after LG.

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P277

Post-Operative Outcomes of Partial Anterior Fundoplication

and Posterior Partial Fundoplication Following Heller Myotomy
for Achalasia

Management of PEG Tube Site Erosion with Negative Pressure

Wound Therapy

Asia Filatov, PhD1, Anastasia Postoev, BA1, Jane Chung, BA2,

Ladoris Latin, BA1, Angel Farinas, MD2, Angelina Postoev, MD2,
Christian Cruz, MD2, Christopher Ibikunle, MD2, Aliu Sanni, MD2,
1
1Department of Surgery, Caribbean Medical University, Chicago IL,
2
2Department of Surgery, UGA/GRU Partnership, Athens, GA
Introduction: Laparoscopic Heller myotomy is considered the most effective treatment for
achalasia, improving quality of life and alleviating symptoms. The addition of a fundoplication prevents postoperative reflux and treatment failure. This study compares the
postoperative outcomes of anterior partial fundoplication (Dor) with posterior partial fundoplication (Toupet) following laparoscopic Heller myotomy.
Methods: A systematic review was conducted to identify relevant studies from 20112014
with comparative data on Dor versus Toupet fundoplication following Heller myotomy.
The primary outcomes were the incidence of post-operative dysphagia and reflux. Other
outcomes included operating time, inter-operative perforation, LES pressure and postoperative hospital stay. Clinical assessments were also performed using a standard grading
system (Vantrappen & Hellemans). Results are expressed as standard difference in means
with standard error. Statistical analysis was done using random-effects meta-analysis to
compare the mean value of the two groups (Comprehensive Meta Analysis Version 3.3.070
software; Biostat Inc., Englewood, NJ).
Results: Five studies were quantitatively assessed and included for meta-analysis, which
included two prospective and three retrospective studies. Among the five studies, 127
patients underwent Dor fundoplication and 139 patients underwent Toupet fundoplication.
Post-operative dysphagia was significantly higher in the Dor fundoplication group when
compared to Toupet fundoplication (-0.475 +/- 0.165, p\0.004).
The incidence of post-operative reflux (-0.170 +/-0.144, p=0.24), intra-operative perforation (-0.213 +/-0.154, p=0.17), LES pressure (0.268 +/- 0.182, p=0.15), OR time (0.12
+/- 0.13, p=0.34) and overall effectiveness (-0.291 +/-0.211, p=0.17) were similar in
both groups.
Conclusions: Toupet fundoplication following Heller myotomy provides less post-operative dysphagia when compared to Dor fundoplication

Tuong Nguyen, MD, Samudra Sanyal, Efrain Aguilar, Jay Strain, Pak
Leung, Mark Kaplan, Einstein medical center
Abstract: Background: Percutaneous endoscopic gastrostomy (PEG) tube has been in use
for over 30 years with increased in rate of utilization. However, placement of PEG tube is
associated with variety of complications. Several studies have reported complications
ranging from 4 to 23.8% of the cases. Erosion of the PEG tube site is a rare complication
and currently there are no literatures on non-operative management of this complication.
Method: Here we present a case of severe erosion of anterior abdominal wall at the PEG
tube site from a gastrocutaneous (GC) fistula managed successfully with negative pressure
wound therapy(NPWT) after failure of conventional therapy. The NPWT dressing consists
of white sponge over the ulcer, Adaptic non-adhesive dressing over the white sponge and
then black sponge on top. This dressing was changed three times a week.
Result: NPWT is an excellent way to control leaking of gastric content around the catheter.
Another benefit of NPWT is its ability to promote wound healing. There was marketed
shrinkage of the ulcer after only 2 dressing changes. After 2 weeks of NPWT the wound
improved significantly and shrink to a circular lesion of less than 2cm in diameter. We
planned to continue NPWT until the wound continues to shrink and heal or to a point where
we can perform skin graft
Conclusion: This is the first case to report the use of negative wound therapy to manage
severe erosion of PEG tube site. Current standard of care for this complication involves
removal of the gastrostomy tube to allow healing and insertion of new gastrostomy tube at a
new site. While there have been several endoscopic or percutaneous methods described in
the literature to close the GC fistulas secondary to PEG tubes, operative management
remains the current standard of care. NPWT is a novel technique to deal with this complication in patients who are not surgical candidates or who cannot go without enteral
access for nutrition.

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P278

P280

The Effect of Immunosuppressive Medications on Early

Outcomes in Bariatric Surgery

The Effecting Factors on the Postoperative Morbidity

in the Patients Who Were Performed Gastric or Colorectal
Resection Because of Gastrointestinal Cancer. Does Preoperative
Nutritional Status Affect to Postoperative Morbidity?

Chetan V Aher, MD, Matthew D Spann, MD, Ronald H Clements,

MD, Wayne J English, MD, D Brandon Williams, MD, Vanderbilt
University Medical Center
Introduction: Immunosuppressed patients undergoing surgical intervention are at increased risk of
postoperative complications. Little is known if there are salutary effects of withholding
immunosuppressive medications in the preoperative period. We report the outcomes of primary
bariatric surgery on immunosuppressed patients at a high-volume, tertiary care center.
Methods: We conducted a retrospective review of all patients undergoing laparoscopic vertical
sleeve gastrectomy or gastric bypass at a single institution from January 2008August 2015. We
analyzed all patients taking long-term, systemic, immunosuppressive medications. We collected
data on 30-day mortality and morbidities including gastrointestinal anastomotic leak, infection, and
bleeding requiring transfusion.
Results: Within the study period, we identified 1,840 patients undergoing bariatric surgery. Sixtyone (3.3%) had taken immunosuppressive medications in the preoperative period. There were no
mortalities or gastrointestinal anastomotic leaks. We identified seven morbidities that occurred in
five patients (8%) including two superficial wound infections, two bleeding episodes requiring
transfusion, one urinary tract infection, one aspiration pneumonia, and one return to the operating
room for small bowel obstruction due to intra-luminal thrombus.
Conclusion: Our results indicate that performing a primary bariatric operation on patients taking
immunosuppressive medications has a low risk of perioperative complications.

P279
Who Are the PPI Non-Responders?
Paul D Colavita, MD1, Christy M Dunst, MD1, Maria A Cassera, BS1,
Kristin W Beard, MD1, Ahmed M Sharata, MD1, Radu Pescarus,
MD2, Kevin M Reavis, MD1, Valerie J Halpin, MD3, Lee L
Swanstrom, MD1, 1Gastrointestinal and Minimally Invasive Surgery
Division, The Oregon Clinic, 2Department of General Surgery,
Hopital Sacre-Coeur, Montreal, QC, 3Legacy Weight and Diabetes
Institute, Portland, OR
Objective: Proton pump inhibitor (PPI) response is often considered a diagnostic strategy for
gastroesophageal reflux disease (GERD). Patients who do not respond to PPI are often left with an
uncertain diagnosis and untreated symptoms. The aim of this study was to evaluate these patients
with GERD symptoms refractory to PPI to determine diagnosis, GERD or otherwise, and to
determine treatment efficacy.
Methods: A prospective database was queried for all patients referred for GERD from 20052013.
PPI non-responders were defined by daily heartburn and/or regurgitation despite daily PPI use. All
patients underwent evaluation with pH-MII, manometry, upper GI contrast study, and EGD per
protocol with selective gastric emptying study. Objective and subjective data were collected from
124 months postoperatively.
Results: Of 1776 patients referred for GERD, 628 met criteria as non-responders. Ten did not
complete their work-up, and 6 were lost to follow-up, leaving 612 in the final cohort. The following
disorders were identified in non-responders: isolated GERD (359), paraesophageal hernia (PEH)
(114), gastroparesis (80), achalasia and other isolated motility disorders (14), symptomatic
cholelithiasis (2), and others (17). Twenty-six patients had a negative work-up.
Surgical procedures were performed on 520 (85%) non-responders. GERD patients underwent 310
anti-reflux procedures, 9 subtotal gastrectomies, and 6 anti-reflux procedures with cholecystectomy. One-hundred and twelve additional patients had PEH repairs with fundoplication. Patients
with gastroparesis underwent 50 pyloroplasties with anti-reflux procedures, 6 isolated pyloroplasties, 1 gastric stimulator placement, and 8 subtotal gastrectomies. Seven Heller myotomies and
5 peroral endoscopic myotomies were performed for isolated gastroesophageal outflow obstruction.
Six patients with other diagnoses underwent procedures.
For GERD patients, 98% had substantial improvement or complete resolution of their heartburn
and regurgitation, with average symptom score follow-up of 7.3 months. All patients with gastroparesis who underwent procedures had substantial improvement or complete resolution of their
heartburn and regurgitation, with average follow-up of 7.1 months. There was no 30 day mortality.
Conclusions: Fifty-nine percent of patients who present with GERD symptoms refractory to PPI
therapy have objective isolated GERD while only 4.2% have a negative comprehensive evaluation.
Twenty-eight percent have GERD and PEH or concurrent gastroparesis, which may explain the
poor PPI response. After careful evaluation, 94% of non-responders will have a surgical diagnosis
identified. Importantly, patients with objectively confirmed PPI refractory GERD enjoy excellent
results with surgical therapy. Overall, the lack of PPI response should not exclude patients from
further foregut evaluation as most will have a treatable disorder.

123

Emine O Gur, Osman N Dilek, Oguzhan Ozsay, Turan Acar, Kemal

Atahan, Erdinc Kamer, Haldun Kar, Mehmet Haciyanli, Katip Celebi
Univercity Ataturk Research and Educational Hospital General
Surgery Department
Introduction: Preoperative nutritional status of the patients is an important factor for the postoperative morbidity. Preoperative evaluation of the nutritional status of the patients with gastric or
colorectal cancer can alert the surgeon about postoperative morbidity. There are several methods to
evaluate nutritional performance of the patients. Nutritional risk screening 2002 (NRS-2002) is one
of them. The aim of the present study is to detect the effecting factors on postoperative morbidity of
gastric or colorectal resection because of the cancer and to evaluate the predictive value of preoperative NRS-2002 score on postoperative morbidity.
Methods and Procedures: The patients who were performed on gastric resection or colorectal
resection because of malignancy were included in the study. Preoperative nutritional status of the
patients evaluated with NRS-2002 system. The patients whose NRS-2002 score were lower than 3
points were accepted as good nutritional performance. The effects of the age, sex, the origin of the
malignancy, preoperative NRS-2002 score, the quantity of the blood transfusion during operation,
stage of the disease, the length of the operation, body mass index, preoperative blood albumin level
on morbidity were evaluated statistically. The effect of morbidity on the length of hospital stay was
also determined.
Results: 418 patients between January 2012December 2014 were included in the study. Ninetynine of all patients (23.6%) had postoperative morbidity. Gastric resection was performed on 196
(46.8%) patients and colorectal resection was performed on 53.2% of the patients. The 64.1% (268
patients) of the patients were male and the overall age was 61.1 12.3 (2488) years. There were
259 patients (61.9%) with good nutritional performance. Postoperative morbidity was developed on
49(18.9%) of the patients who had good nutritional score. The morbidity rate was 31.4% in the
patients with poor nutritional performance (p\0.05). The stage of the disease, length of the
operation, and the quantity of the blood transfusion during the operation were effecting the morbidity rate significantly (p\0.05). The mortality rate was 2.3% in our study group.
Conclusion: The preoperative nutritional performance, the stage of the disease, length of the
operation, and the quantity of the blood transfusion are affecting factors on the postoperative
morbidity of the patients who were performed gastric or colorectal resection because of the cancer.
The preoperative evaluation of the nutritional status of the patients with NRS-2002 in surgery
clinics can be a predicting method for postoperative morbidity on the patients who were performed
resection because of gastric or colorectal cancer.

P281
Bariatric Surgery in the SuperSuper Obese: Outcomes
of Weight Loss and Effects on Medical Co-Morbidities
Maureen V Hill, MD1, Ian C Bostock, MD, MS1, Sarah E Billmeier,
MD, MPH1, Escar Kusema2, Maureen Quigley, APRN1,
Gina L Adrales, MD, MPH, FACS1, 1Dartmouth Hitchcock Medical
Center, 2Dartmouth Geisel School of Medicine
Introduction: Laparoscopic roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG) have
both been shown to be safe and effective in achieving excess weight loss (EWL) in the super-super
obese (SSO) (BMI[60). Our purpose was to examine the efficacy in terms of medical co-morbidity
resolution in addition to weight loss.
Methods and Procedures: A retrospective review was performed of all bariatric surgical patients
with a BMI [60 treated at our institution between June 2009 and January 2015. The primary end
point was %EWL at each follow up interval (1, 4, 8, 12 months and 2 years). Secondary endpoints
were resolution of medical comorbidities (diabetes, hypertension, obstructive sleep apnea (OSA),
CPAP use, and GERD). Resolution of diabetes and hypertension was defined by cessation of all
associated medications with continued normal fasting blood glucose levels and blood pressure,
respectively. GERD resolution was defined as lack of symptoms off medication, and OSA resolution was defined as titration and cessation of CPAP use (if applicable) with no continued
symptoms. The statistical analysis was performed using student T test, and a p value \0.05 was
considered statistically significant with a confidence interval of 95%. For categorical variables, an
analysis to determine frequencies, proportions, and Chi2 was also performed.
Results: Fifty nine SSO patients were identified for which we had follow up information on 55.
Forty seven underwent RYGB and 12 underwent LSG. Mean BMI was 68.15 (6.96 SD). The
average %EWL at each follow up interval for patients undergoing RYGB or LSG at 1, 4, 8 12
months and 2 years respectively were 21.1%, 29.2%, 45.0%, 46.9% and 50.9%. There was a
significant decrease in the incidence of hypertension (69.5% vs. 40.7%, p\0.05), OSA (88.1% vs.
62.7%, p\0.05), and CPAP use (84.7% vs. 54.2%, p\0.05) on follow up. There was a trend
towards resolution of diabetes (52.5% vs. 22%, p=0.06).
Conclusion: Bariatric surgery is effective in achieving both weight loss and in improving medical
comorbidities in the super-super obese. This may have implications in reducing healthcare resource
utilization by this challenging patient population.

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P282

P284

A Retrospective Study of Esophagectomy Outcomes:

An Institutional Review

The Advantages of Imatinib for the Surgical Treatment

of Gastrointestinal Stromal Tumour of the Esophagus

Vernon Horst, MD1, Hetal Patel, MD1, John G Touliatos, MD,

FACS2, 1Baptist Health System, 2Advanced Surgeons, PC

Ali Kagan Coskun, MD, GATA Dept. of Surgery

Introduction: We set out to compare our minimally invasive trans-hiatal esophagectomy outcomes with
minimally-invasive Ivor-Lewis esophagectomy outcomes. Esophageal cancer is an uncommon but highly
lethal disease. Invasive esophageal cancer (greater than Stage II) has a low 5-year survival rate. Treatment
options are both surgical and non-surgical, with surgical options including esophageal stents, endoscopic
ablation, and surgical resection, with resection being the gold standard of therapy. Resection is also indicated for palliation. Esophagectomy, traditionally performed by laparotomy and right thoracotomy, carries
an expected prolonged convalescence with complicated hospitalization and high peri-operative morbidity
and mortality rates. Some studies have demonstrated benefit with minimally invasive esophagectomy.
Methods and Procedures: Charts for all patients who underwent esophagectomy by our attending surgeon,
John Touliatos, from 20082014 were reviewed. Data collected included cancer stage, number of nodes
resected, anastomotic leak rates, mean duration of naso-gastric tube, length of stay, and 30-day perioperative mortality.
Results: We demonstrated a considerably improved outcome with minimally-invasive trans-hiatal
esophagectomy when compared to Ivor-Lewis esophagectomy. Patients who underwent minimally-invasive
trans-hiatal esophagectomy had fewer anastomotic leaks, a lower 30-day peri-operative mortality, and a
mediastinal node harvest that was equivalent to or greater than patients who underwent Ivor-Lewis
esophagectomy.
Conclusion: Trans-hiatal esophagectomy shows promise as a valid option for esophageal resection,
including in advanced stages of cancer. We recognize the small sample size of both groups; however, in our
patient population the trans-hiatal approach had a significantly improved benefit when comparing perioperative mortality and morbidity, hospitalization length of stay, naso-gastric tube duration, and anastomotic
leak rates. We propose that this a safe and appropriate approach for esophageal resection in all advanced
stages of cancer in the hands of the experienced laparoscopic surgeon.

P283
Endoscopic, Laparoscopic and Open Surgical Treatment
Modalities of Gastric Gastrointestinal Stromal Tumors
Adem Akcakaya, Prof1, Kemal Dolay, Prof1, Mustafa Hasbahceci,
MD1, F.Betul Akcakaya, Ms2, Ibrahim Aydogdu, MD2, 1Bezmialem
Vakif University Medical Faculty Department of Surgery,
2
Bezmialem Vakif University Medical Faculty
Introduction: The aim of the study was to evaluate the effect of tumor size and localization on choosing
treatment modalities and also to compare the efficacy of endoscopic, laparoscopic and open surgical
treatment of gastric gastrointestinal stromal tumors (GISTs). GISTs are rare and constitute only 1% of all
malignant tumors of the GI tract while Gastric GISTs comprise only 13% of all malignant gastric tumors.
Methods and Procedures: We retrospectively reviewed all patients with a diagnosis of gastric GISTs.
Between January 2008 and December 2014, 28 patients with gastric GIST who underwent laparoscopic
wedge resection (Group 1, n=7), endoscopic enucleation (Group 2, n=5) and surgery (Group 3, n= 16) at
Bezmialem Vakif University Medical Faculty Hospital and Sisli Training and Research Hospital were
included.
Results: There were 28 patients who have gastric GIST (17 male, 11female) with a mean age of 56.412
years (range 2376). Mean tumor size was 65.948mm (range 22200) for Group 1, 58.823 mm; for
group 2, 26.84mm; for group 3, 81.2556 mm. There were statistically significant differences between the
groups according to the tumor size. Smaller the tumor size caused the chance of endoscopic enucleation to
increase. Location of tumors were the fundus and cardia in 8 patients (28%), the corpus in 9 (32%), the
antrum in 5 (17%), bi-zonal in 6 (21%). No cardia tumor was seen in laparoscopic wedge resection groups
(Groups 2). Total gastrectomy, subtotal gastrectomy and wedge-segmental resection were performed in 5, 5
and 6 patients, respectively (Groups 3). There were no major operative complications or mortalities. All
lesions had negative margins. Endoscopic surveillance was accomplished in 26 patients (93 %) with no local
or distant recurrences during follow up of each patient.
Conclusion: Tumor size of Gastric GISTs is the primary factor in choosing the resection method. Surgical
modalities are secondarily associated with tumor localization. Endoscopic enucleation and laparoscopic
wedge-segmental resections can be preferred in patients with small and medium sized gastric GISTs,
respectively. Larger tumors necessitate subtotal or total gastrectomy

Gastrointestinal stromal tumors (GISTs) are common neoplasms of the digestive tract. They are usually seen
in the stomach and small intestine but rarely in the esophagus. Imatinib is a tyrosine-kinase inhibitor. It
shows an advantage in treatment of the patients with locally advanced and metastatic GIST. In this review,
we aim to evaluate the management and outcome of surgery for esophageal GISTs and the role of imatinib.
Methods: PubMed/MEDLINE resources search was undertaken using terms esophageal, stromal,
imatinib in English language . Totally 44 articles were identified, although 21 of them under dissected that
met our inclusion criteria included.
Results: Apart from two articles, the others were case report and case series. The total number of patients
was 71. 70 patients had undergone surgical treatment. Neoadjuvant imatinib was used in 18 patients,
reducing mean tumour size (45.1%). In 4 patients there werent any change in tumor size but decrease in
attenuation were detected with neoadjuvant imatinib. Imatinib was used as adjuvant treatment in 35 patients.
Two of the patients who had an adjuvant treatment, had a recurrence in 30 and 31.5 months after surgical
resection. %45 of the patients who hadnt gotten any treatment of imatinib had a reccurrence in 36 months.
The average follow-up time in the studies was 29 months.
Conclusion: The use of imatinib for esophageal GISTs before or after the surgery has some advantages for
the patients by improving the quality of life and survival.

P285
Esophageal Adenocarcinoma Stage III: Survival Based
on Pathological Response to Neoadjuvant Treatment
Katrin Schwameis, MD, Zehetner Joerg, MD, Jeffrey A Hagen, MD,
Daniel Oh, MD, Stephanie Worrell, MD, Kais Rona, MD, Nathan
Cheng, Kyle Green, Jamil Samaan, Steven R DeMeester, MD,
John C Lipham, MD, Keck hospital, USC
Background: Neoadjuvant chemo- and chemoradiotherapy (CTX and CRT) are considered the gold standard in the treatment of locally advanced adenocarcinomas of the distal esophagus (EAC) prior to surgical
resection. The degree of pathological response to neoadjuvant treatment is thought to be a major prognostic
factor for survival after surgical resection, however limited data exists.
Aim of the Study: To compare the survival of complete and incomplete responders to neoadjuvant
chemo(radio)therapy in patients with stage III EAC. Furthermore, to determine the frequency of complete
response in stage III disease.
Methods: A retrospective chart review was performed of all patients that underwent neoadjuvant therapy
and esophagectomy for stage III EAC between 01/1999 and 08/2013. Demographic, clinical, histopathological and survival data were collected and analyzed. Patients were classified into complete (no residual
tumor; pCR) versus incomplete responders (residual tumor; pIR) to neoadjuvant CTX/CRT based on the
findings in the esophagectomy specimen.
Results: 101 EAC stage III patients (m:f=92:9) underwent esophagectomy at a mean age of 62.7 (2684)
years. 21.8% (n=22) and 78.2% (n=79) had received CXT and CRT, respectively. R0 resection was achieved
in 95% (n=96). pCR and pIR was found in 19.8% (n=20) and 80.2% (n=81). Overall mean F/U time was
34.5 (0.2172.9) months. The overall mean survival was 18.6 (0.2111.8) months while it was 18.8
(0.2111.8) and 17.5 (1.158.7) months for pIR and pCR, respectively (p=0.8). 3-year-survival in pIR and
pCR was 35.5% and 52.9% respectively (p=0.18). Positive lymph node status (ypN+) was found in 54
patients (66.7%) of pIR group and none of the pCR patients. 3 year survival was 53.8% in ypN0 and 28.3%
in ypN+ (p=0.02*).
Conclusion: A complete pathologic response of 20% was found in this series. Complete responders were
found to have a trend toward better survival compared to incomplete responders at 3 year follow up.
Residual lymph node status was a stronger prognostic factor than pathologic response with a significant
survival benefit in node negative patients (Fig. 1).

Fig. 1 Survival of complete vs. incomplete responders to neoadjuvant therapy

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P286

P288

Pulmonary Abscess as a Rare Complication of Gastroesophageal

Reflux Disease

Comparison of Early Experience and Learning Curves Associated

with Minimally Invasive Hiatus Hernia Repair

Robert J Blue, DO, Jason Kempenich, MD, Keesler Medical Center

Paul Del Prado, MD1, Rachit D Shah, MD2, Gretchen Aquilina, DO1,
Guilherme M Campos, MD, PhD1, James G Bittner IV, MD1,
2
Virginia Commonwealth University, Medical College of Virginia,
Department of Surgery, Division of Cardiothoracic Surgery,
Richmond, Virginia, 1Virginia Commonwealth University, Medical
College of Virginia, Department of Surgery, Division of Bariatric
and Gastrointestinal Surgery, Richmond, Virginia

Background: Gastroesophageal reflux disease (GERD) is quite common, and its presentation most
often includes heartburn and regurgitation. Extraesophageal symptoms such as cough, laryngitis,
and asthma have been associated with GERD. Occasional more rare complications, such as pulmonary abscess, have also been noted. Pulmonary abscess is typically a result of aspiration due to
reflux of gastric contents. This case is a rare example of a pulmonary abscess caused by GERD.
Case Description: A 70 year-old male presented with a three-day history of chest pain and cough
with hemoptysis. He was found to have a leukocytosis and neutrophilia without fevers, chills, or
night sweats. His medical history was significant for hypertension, hyperlipidemia, GERD, gout,
depression, and excision of multiple squamous cell carcinomas of the skin. He also had a remote
smoking history. During initial workup, a pulmonary abscess was discovered and treated with oral
antibiotics. The patient failed an initial course of clindamycin, but he was subsequently treated to
resolution of symptoms with amoxicillin and clavulanate.
Due to the patients self-reported forty-year history of GERD, he continued to have significant
sensation of regurgitation, nocturnal cough, and dysphagia. Barium swallow revealed a moderatesized hiatal hernia and severe spontaneous reflux to the upper thoracic esophagus. With no other
etiology of pulmonary abscess revealed after work up, aspiration pneumonia as a complication of
GERD was identified as its source. The patient elected to undergo laparoscopic repair of his hiatal
hernia with Nissen fundoplication. He recovered appropriately with complete resolution of his
symptoms.
Conclusion: Lung abscess is a rare pulmonary complication of GERD. The most common cause of
pulmonary abscess is aspiration pneumonia, and conditions such as dysphagia and reflux greatly
increase the risk of nocturnal aspiration. Thus, it is surprising that this complication has not been
documented more frequently. Further recounting of cases of severe GERD complicated by pulmonary abscess will help characterize patients who are at the greatest risk for this complication.

Objectives: Minimally invasive hiatus hernia (HH) repair is a complex procedure with a significant
learning curve. Few publications report outcomes of surgeons trained in different specialties during
their early learning curve. The study objectives are to document clinical outcomes of minimally
invasive HH repair during the early learning curve and compare simultaneous learning curves
across surgical specialties.
Methods: From November 2012 to August 2015, all consecutive patients who underwent minimally invasive HH repair at a large urban university hospital by one of two fellowship-trained
surgeons early in their clinical experience were included. The surgeons fellowship training differed by specialty (MIS-minimally invasive surgery vs. CT-thoracic and esophageal surgery). Both
individuals began practice in 2012 with simultaneous learning curves. Prospectively collected data
were evaluated and patients were grouped by surgeon specialty to compare outcomes and learning
curves. Data are compared between surgeon type using non-parametric tests (a=0.05).
Results: Ninety-three consecutive patients (MIS 46, CT 47) with mean age 59.4 years (median
ASA 3) underwent laparoscopic (MIS 54%, CT 68%, P=0.2), robotic (MIS 46%, CT 28%, P=0.09),
or thoracoscopic (CT 4%) HH repair. Most patients were female (67%), had types II (20%), III
(42%), or IV (7%) HH, and at least one co-morbidity including hypertension (51%), obesity (47%)
or hypercholesterolemia (33%). Mean operative time was 287 minutes, 51 patients underwent
Nissen fundoplasty (MIS 78%, CT 32%, P\0.01), 24 had partial fundoplication (MIS 15%, CT
36%, P\0.01), 18 had no anti-reflux procedure (MIS 6%, CT 32%, P\0.01), and 14 needed
gastrostomy (MIS 1%, CT 28%, P\0.01). Sixty patients (65%) received mesh reinforcement (MIS
48%, CT 26%, P=0.03) and 18 underwent thoracostomy for capnothorax (MIS 1%, CT 38%,
P\0.01). Perioperative complications excluding capnothorax occurred in 17 patients (MIS 19%,
CT 23 P=0.8) and included esophageal perforation (4%), esophageal stricture requiring dilation
(3%), mediastinal hematoma (1%), and subphrenic abscess (1%). Acute reoperation was necessary
in 6 patients (MIS 4%, CT 8.5%, P=0.7) for perforation/leak, re-herniation, or mediastinal
hematoma. Overall hernia recurrence rate was 6.5% with 3 recurrences in each cohort. The learning
curves of each surgeon were statistically similar based on operative times. The trend was for
operative times to increase from cases 12 to 24 as surgeons took on more complex patients and then
decrease between cases 25 to 46.
Conclusions: Surgeons early in their clinical experience with distinct specialty training perform
minimally invasive HH repair safely with comparable learning curves and perioperative outcomes.

P287

P289

Laparoscopic Paraesophageal Hiatal Hernia Repair with Bio-A

Mesh. Short-Term Results

Atrial Esophageal Fistula Secondary to Ablation for Atrial

Fibrillation: A Case Series and Review of the Literature

Agustin Duro, MD, Demetrio Cavadas, MD, PhD, Axel F Beskow,

MD, Fernando G Wright, MD, Santiago Lenzi, MD, Juan R Medici,
MD, Pablo J Castellaro, MD, Hospital Italiano de Buenos Aires

Lily K Fatula, BS1, William D Bolton, MD2, Barry R Davis, MD2,

James E Stephenson, MD2, Sharon Ben-Or, MD1, 1University
of South Caroline School of Medicine Greenville, 2Department
of Surgery, Greenville Health System

Background: The use of mesh during hiatal hernia repair is controversial. Different types of
prosthesis have been proposed in order to reduce anatomic recurrence but none has yet proven any
benefit. The aim of this study was to evaluate the short-term outcomes of hiatal hernia repair with
the use of a synthetic absorbable mesh in terms of recurrence rate, morbidity and mortality.
Methods: We retrospectively analyzed 42 patients who had crural reinforcement during paraesophageal hiatal hernia repair with a polyglycolic acid trimethylene carbonate bioabsorbable mesh
(GORE BIO-A). All patients were treated by laparoscopy, with a four-trocar technique and a
Nathanson liver retractor. Transhiatal esophageal dissection was undertaken until at least 3 cm of
intra-abdominal esophagus was achieved without tension. Posterior cruroplasty was done using
interrupted 0 silk suture and reinforced with a U-shaped mesh onlay. Hiatus closure was always
calibrated with a 58 French bougie. The procedure ended with a Nissen fundoplication. Barium
esophagram was systematically performed at 1, 6 and 12 months postoperatively or when new
onset of symptoms occurred. Recurrence was defined as any protrusion of the wrap above the
diaphragm.
Results: There were 29 women and 13 men with a mean age of 61.5 years (3582). No complications related to the mesh appeared. The overall morbidity was 11.9%. One patient with CREST
syndrome who had a preoperative esophageal stricture and a manometry with aperistalsis presented
with acute dysphagia caused by food bolus impaction and required endoscopic dilatation. Other
complications include: pulmonary embolism (2), atrial fibrillation (1) and pleural effusion (1).
There was no postoperative mortality. Mean follow-up was 15.5 months (632). Sixty-nine percent
of patients had more than one year of follow up. There were three recurrences (7.14%) with a mean
time to diagnosis of 17,3 months (1224).
Conclusion: The use of this synthetic bioabsorbable mesh for the treatment of large paraesophageal hiatal hernias is safe and may reduce recurrence rate in the short-term. Further follow-up
is needed to evaluate long-term results.

123

This report describes presenting symptoms, diagnostic modalities, and survival outcomes in
patients with left atrial esophageal fistula (AEF) secondary to catheter ablation for atrial fibrillation
(AF), including two patients who recently presented to our institution within a 2-month timespan.
Although rare, incidence of AEF is increasing and carries a high mortality rate. Approximately 50
reports of AEF following AF ablation have been described. Both patients at our institution presented with fevers and neurological deficits.
Patient 1, a 57-year-old man, presented 31 days post ablation with a fever and right-sided weakness.
A chest CT showed gas in the left atrium and esophagus; an echocardiogram confirmed the
diagnosis of AEF. The patient subsequently underwent a left thoracotomy. Post-operative recovery
was poor and included acute tubular necrosis, liver failure, and worsening cerebral edema. The
patient was removed from life support and expired on post-operative day (POD) 28.
Patient 2, a 77-year-old man, presented 21 days post AF ablation with left arm weakness and
altered mental status. An esophagram was performed and showed no evidence of an esophageal
perforation. The patient, however, was admitted and, following worsening conditions, underwent a
head CT which showed pneumocephalus, leading to our suspicion of the AEF. A follow-up chest
CT confirmed the AEF. Treatment included an esophagectomy and repair of the atrium. At this date
(POD 6), the patient is alive, but remains on a ventilator. Fever, neurological deficits, hematemesis,
altered mental status, and chest pain are the primary presenting symptoms in patients with AEF;
these same symptoms were seen our patients. With regards to diagnostic modalities, chest CT and
head CT are the leading methods reported. Head and chest CT also proved to be the most accurate
diagnostic tools for our patients. Lastly, the reported mortality rate associated with AEF is 4080%.
However, the literature has shown speed of diagnosis and treatment to improve a patients chance
of survival. In conclusion, we recommend that a chest CT be immediately performed on patients
presenting with the described symptoms following a recent AF ablation.

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P290

P292

Incidence of Diaphragmatic (Paragastric) Hernias Following

Transthoracic Esophagectomy: Comparison of Open, MIS,
and Hybrid Approaches in 115 Patients

The Value of Laryngopharyngeal pH-Metry (Restech)

in Patients with Gerd and Extraesophageal Symptoms

Brian Biggerstaff, MD, Steven Cheung, MD, Bertellotti Carrie,

APRN, Sumeet Mittal, MBBS, Creighton University Department
of Surgery
Objectives: Compare incidence of post-esophagectomy paragastric hernias (PGH) based on type of surgical
access (MIS vs open) with respect to thoracic and abdominal approaches.
Methods: After institutional review board approval the esophageal center database was queried to identify
patients who underwent Ivor-Lewis or McKeown esophagectomy for malignant disease and extracted into
an excel sheet. All patients underwent surveillance CT scans at routine intervals (3,6,9,12,18,24,36,48 and
60 months). Patients were classified as having undergone open, MIS, or hybrid procedures. PGH was defined
as radiographic evidence of herniated viscera through the diaphragmatic hiatus next to the stomach. We
compared the incidence of PGH according to surgical access. Patients with less than 1 year survival were
excluded.
Results: Between September 2004 and December 2014, 279 esophagectomies were performed at a single
institution. 115 patients (avg age 62.0 yrs, 98 Males) met inclusion criteria: 59 had Ivor-lewis and 56
McKeown procedures. Overall incidence of PGH was 13%. Mean time to diagnosis was 7.8 months (024
months). Open thoracic (10.6% vs 14.7%) and open abdominal (5.6% vs 16.5%) approaches were associated
with lower incidence of PGH compared to their MIS counterparts. Individual groups were associated with
the following incidences (thoracic/abdominal): 1) open/open: 6.7%, 2) open/MIS 17.6%, 3) MIS/open: 0%,
and 4) MIS/MIS: 16.2% (p=0.42). There were 8/59 (13.6%) PGH in Ivor-Lewis group compared to 6/56
(10.7%) in the McKeown group. None of these achieved statistical significance.
Conclusion: MIS approach, especially for abdominal access, appears to be associated with a higher incidence of PGH following transthoracic esophagectomy. Series with higher power are needed to confirm these
findings.

Hans F Fuchs, MD1, Henner M Schmidt, MD2, Sebastian Brinkmann,

MD1, Wolfgang Schroder, MD1, Christian A Gutschow, MD2, Arnulf
H Holscher, MD1, Jessica M Leers, MD1, 1Department of Surgery,
University of Cologne, Germany, 2Department of Surgery, University
Hospital Zurich, Switzerland
Introduction: The evaluation of extraesophageal reflux symptoms is difficult and mostly based on patients
history. With the introduction of Restech objective measurements of laryngopharyngeal reflux became
possible. The aim of this study is to evaluate the value of Restech in patients with GERD and extraesophageal refluxsymptoms.
Methods and Procedures: Retrospective analysis of all patients who received a complete diagnostic workup for reflux including symptoms, endoscopy, 24h pH-metry, high resolution manometry and Restech. For
comparison a well evaluated scoring system was used (Fig. 1).
Results: A total of 26 patients consecutive patients from 12/201303/2015 were included. They all had
extraesophageal symptoms such as cough (54%), hoarseness (42%), globus sensation (31%) and asthma
(8%). Classical symptoms such as heart burn (58%), regurgitation (46%), odynophagia (19%) and retrosternal pain (19%) were also present. Extraesophageal symptoms without classical symptoms existed in 2
patients (18%). The 24 hours pH metry was positive in 73% (n=19, DeMeester Score 96 [16285]) and
normal in 27% of patients (n=7, DeMeester-Score=9 [014]). Restech evaluation in patients with pathologic
pH metry was positive in 8/19 cases (median DeMeester-Score=69 [16285], median Ryan score=210
[35650]). In 71% pf patients with normal pH-metry, Restech evaluation was pathologic (n=5, median
DeMeester-score=12 [1014], median Ryan score=67 [5582]).
Conclusions: Restech Evaluation was positive in more than 50% of cases. Especially in patients with
borderline elevated results in 24 hour pH metry, the restech examination helps support the decision for or
against surgery. To validate this technique further studies which include post-operative data are necessary
and currently ongoing.

P291
Spontaneous Perforation of Jejunal Gastrointestinal Stromal
Tumour (GIST): Rare Presentation of the Rare Tumor in a Rural
Hospital. Case Report and Review of Literature
Sharvani Kanakraddi, Ajit Kanakraddi, venkatesh Hospital
Introduction:GISTs are rare group of tumors originating from interstitial Cajal cells of digestive tract. They
account for 0.13% of all gastrointestinal tumors and have a frequency of 1020/1,000,000 population; they
were previously identified as leiomyomas, leiomyosarcomas or leiomyoblastomas; and now are reclassified
on immunohistochemical features, with a positive expression of Kit (CD117 antigen). They are usually
located in the stomach (60%), small intestine (2030%) and 10% occur in other parts of the GI tract.
Generally, GISTs have a silent behavior and are diagnosed incidentally; they are difficult to diagnose and
often advanced at the time of definitive treatment. Symptoms are highly dependent on the size and location
of the tumor. They are characterized by indolent clinical symptoms including vague abdominal pain, weight
loss, occult GI bleeding and obstruction, however, we present a case of perforated GIST located in the
jejunum as a rare cause of acute abdomen. Spontaneous perforation of GIST is an extremely rare presentation and occurs due to haemorrhagic necrosis.
Typically, GISTs tend to invade locally and spread by direct extension into adjacent tissues and rarely
hematogenously to the liver, lungs, and bone; lymphatic metastases are unusual; their malignant potential is
2030% The most useful indicators of survival and the risk for metastasis include the size of the tumor at
presentation, the mitotic index, and evidence of tumor invasion into the lamina propria.
Case Presentation: A 50 year old male presented with sudden onset of pain abdomen, vomiting and fever
since 3days.0/E he was haemodynamically stable and had tenderness, guarding and rigidity all over
abdomen. Complete haemogram was normal. Ultrasound abdomen revealed only mild ascites; X-ray erect
abdomen had air under the right diaphragm. During exploratory laparotomy there was a perforated exophytic growth of size 6x 6 cm which was communicating with lumen of jejunum; the growth was around 15
cm from DJ flexure. After adequate peritoneal lavage, tumuour was resected with 5cm margin and end to
end anastomosis of bowel was done. HPR revealed GIST with R0 clearance. Immunohistochemistry was
positive for CD-117 antigen. Patient is on oral imatinib since 3 months.
Discussion: There have been only 15 reported cases of perforated GISTS in the literature. Complete removal
with postoperative imatinib therapy entails optimal treatment. The 5-year survival rate is 35%. It increases to
54% after complete surgical excision. However 40% will recur within 18 24 months. Once recurrence has
occurred median survival is 916 months.

Fig. 1 Restech device in place, transoral view

P293
Repair of Symptomatic Paraesophageal Hernias in Elderly ([70
Years) Patients Results in Sustained Quality of Life at 5 or More
Years
Oleg V Merzlikin, MD, Brian E Louie, MD, Alexander S Farivar,
MD, Dale Shultz, Ralph W Aye, MD, Swedish Medical Center
Introduction: Paraesophageal hernias (PEH) involve herniation of stomach and/or other viscera into the
mediastinum resulting in symptoms that reduce quality of life (QOL). Surgical repair in the elderly has low
morbidity and results in significant improvement in QOL in the short term. There is a paucity of long-term
data detailing the outcomes. Without this data, patients or their physicians may eschew surgery due to
advanced age, concerns about comorbidities, and life expectancy despite reduced QOL. We evaluated the
long-term QOL in elderly patients at least 5 years after repair.
Materials and Methods: We performed a retrospective chart review of consecutive patients 70 or greater
who underwent PEH repair between 20032010. The PEH was required to be 5+ cm in axial length with a
paraesophageal component. Quality of life was assessed preoperatively, at 1224 months and at 5+ years
using QOLRAD, GERD-HRQL and a dysphagia score.
Results: A total 73 patients underwent surgical repair. Five patients were lost to follow up leaving 68
patients for analysis including 27 (40%) males and 41 (60%) females. Median age at repair was 77.6 years
(IQR 73.182.3). There were two 90-day mortalities (2.4%), with one occurring within 30 days of surgery.

Overall, QOLRAD improved from 5.0 to 6.9 (p=0.002), GERD-HRQL improved from 13 to 2
(p=0.0003) and dysphagia improved from 12 to 45 (p=0.01) at a median follow up of 6.4 years.
During follow up, 22 (30%) patients died at a rate similar to the population. Deceased patients lived a
median of 4 years (IQR 1.45.3) after repair with a median age at repair of 80.2 years (IQR 76.684.9). At a
median follow up of 1.6 years, this group reported QOLRAD improved from 5.9 to 7.0 (p=0.05), GERDHRQL improved from 14 to 4 (p=0.03) and dysphagia improved from 17 to 34 (p=0.02).
In the surviving 46 patients median follow up was 7.4 years (IQR 6.78.76). There were 7 recurrences. From
pre-operative to short term to long term, QOLRAD improved from 4.4 to 7.0 to 7.0 (p=0.01); GERD-HRQL
improved from 11.5 to 3 to 1 (p=0.0002) and dysphagia improved from 12 to 18 to 45 (p=0.01)
Conclusions: In elderly patients, surgical repair of a symptomatic PEH results in sustained improvement in
quality of life. Ninety-day mortality was low and patients who died in follow up survived 4 years after
surgery with good quality of life. These results justify surgical repair of symptomatic PEH in the elderly.

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P295

Intracorporeal Esophagojejunostomy Using the Hemi-Double

Stapling Technique (HDST) After Laparoscopic Total
Gastrectomy in Gastric Cancer Patients

Patient Centered Outcomes Over Time After Redo-RNY

for Failed Fundoplication

Bandar Ali, MD, The catholic university of Korea, Seoul St.Marys

hospital
Purpose: To present technique proposed by the author with its technical details on reconstruction with
HDST, feasibility and safety of circular stapling technique during esophagojejunostomy in totally gastrectomized gastric cancer patients.
Methods: A retrospective case-series study between July 2010 and December 2014, 58 consecutive patients
with gastric cancer underwent laparoscopic assisted total gastrectomy (LATG) in Seoul St. Marys hospital
were enrolled for study. We performed a simple and safe Roux-en-Y esophagojejunostomy using hemidouble stapling technique (HDST). All patients characteristics, perioperative outcome and histopathologic
data were reviewed.
Results: The mean age and body mass index were 57.3 9.7 years and 23.7 2.6 kg/m2 respectively. The
mean overall total operation including reconstruction and anvil insertion times were 199.8 57.0 min. Intra
operative blood loss was 81.6 56.3 mL and there was no open conversion. Splencetomy was needed
initially in only 2 patients (3.4%). The postoperative complications divided to EJ anastomosis site and non
EJ anastomosis site. In EJ site was 5(8.6%) cases of leak were all controlled successfully by endoscopic
stent, 3(5.1%) cases of anastomosis stricture were treated all successfully by endoscopic intervention except
for 1(1.7%) case needed surgical intervention. A-loop partial obstruction was encountered in 3(5.1%) cases
were treated conservatively, 1(1.7%) case of A-loop bleeding was treated conservatively as well. Non EJ site
complication in majority was chest related complications i.e. pneomnia in 3(5.1%) cases, pleural effusion in
4(6.8%) cases, pancreatitis in 2(3.4%) cases, splenic bleeding in 1 case necessitated splenectomy to control
bleeding. Intra abdominal fluid collection was in 6(10.3%) cases, wound infection in 2(3.4%) case, wound
disruption in 1(1.7%) cases, ileus in 5(8.6%) cases and trocar site hematoma in 1(1.7%) case. The patients
were hospital stay at a mean of 9.6 2 days. The mean proximal margin of specimen was 2.7 1.8 cm.
Conclusion: Roux-en Y esophagojejunostomy using method of circular hemi double stapling technique is
simple, safe and rapid. It may offer a solid, alternative reconstruction method in totally gastrectomized
patients.

123

Shunsuke Akimoto, Saurabh Singhal, Sumeet K Mittal, Creighton

University Medical Center
Introduction: As Antireflux surgeries have become common, more patients are presenting with need for
reoperative interventions. We assessed our patient for short, mid and long term subjective outcome following redo Roux-en-Y reconstruction (RNY) for failed fundoplications.
Methods: After IRB approval, we identified patients who had undergone redo RNY between December
2003 and June 2010. Database contains patient follow-ups. Patients with short term follow-up (12 years)
form group A, those with mid-term follow-up 25 years (Group B) and those with long term follow-up ([5
years) for group C. Patient reported symptoms [0(low)3(high)], satisfaction [1(low)10(high)] and use of
medications was compared between the groups. We decided symptom score 2 and 3 as severe symptom. We
decided satisfaction score 810 as excellent satisfaction.
Results: A total of 203 patients underwent redo-anti-reflux surgery during the study period, of which 70
patient who had undergone RNY formed the cohort for this study. Follow-up at short term, mid term and
long term was available for 25 patients, 41 patients and 21 patients respectively. Severe symptoms were not
significantly different among all groups (heartburn: 16% vs. 19.5% vs. 28.6%, dysphagia: 20% vs. 14.6% vs.
19%, regurgitation: 8% vs. 4.9% vs. 4.8%, chest pain: 4% vs. 2.4% vs. 9.5%, respectively, all values p
[0.05). Proportion of patients reporting excellent satisfaction increased overtime but it was not statistically
significance (64% vs. 82.9% vs. 76.2% p [0.05).
Conclusion: Redo RNY patients following failed fundoplications show excellent satisfaction in long term
with no worsening of symptoms.

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P296

P297

Impact of Poem on High-Resolution Motility Findings in Patients

with Type II and III Achalasia

Ivor- Lewis Esophagectomy with Circular Stapled Anastomosis

(EEA): Single Centre Experience

Katrin Schwameis, MD, Stephanie Worrell, MD,

Steven R DeMeester, MD, Keck Hospital, USC

Saurabh Singhal, MBBS, MS, Aparna Kailasam, Shunsuke Akimoto,

MD, Carrie Bertellotti, RN, Sumeet K Mittal, MBBS, Creighton
University

Background: High-resolution manometry (HRM) identifies three subtypes of achalasia. Type II, with panesophageal pressurization (PEP), and Type III with distal spastic contractions appear very different on HRM
to the flaccid body and lack of PEP in patients with Type I achalasia. Per-oral endoscopic myotomy (POEM)
relieves the outflow obstruction at the lower esophageal sphincter (LES) without adding new resistance from
the addition of a partial fundoplication. The aim of this study was to evaluate HRM changes in patients with
achalasia Types II and III after POEM.
Methods: We reviewed the records of all patients with achalasia Types II and III that underwent POEM and
had both pre and post-operative HRM, upper endoscopy and timed barium swallow (TBS).
Results: There were 31 patients that had POEM for achalasia Types II or III and 16 patients, 12 Type II and
5 Type III, had pre and post-POEM studies at a median of 4.9 months. All patients with Type II and 2/5
patients with Type III achalasia showed PEP pre-POEM. Post-POEM, PEP resolved in 72.7 % of type II
patients (Fig. 1) but in none with Type III (Table 1). The mean IRP and LES resting pressure were
significantly reduced after POEM, and was similar for Type II and III achalasia (p=0.33 and 0.75 respectively). However, post-POEM IRP was lower in those with resolution of PEP compared to those with
persistent PEP (9.5 vs. 16.7, p= 0.025). There was no difference in the LES resting pressure post-POEM in
those with and without resolution of PEP (14.9 mmHg vs 20.7 mmHg, p= 0.18). Compared to those with
residual PEP, those with resolution of PEP had similar dysphagia relief (80% vs 75%, p=0.84), esophageal
emptying on TBS (97% at 5 min vs 89% at 5 min, p=0.16) and frequency of post-POEM esophagitis (60%
vs 62.5%, p=0.93). No patient with Type II achalasia had return of peristalsis post-POEM compared to 2/5
(40%) with Type III achalasia. No Type III patient on post-POEM HRM looked like Type I or II.
Conclusions: POEM leads to significant relief of LES outflow resistance and resolution of PEP in most
patients with Type II achalasia. Persistent PEP was associated with a higher post-POEM IRP but not resting
pressure, and similar symptom relief, improvement in TBS esophageal emptying and frequency of
esophagitis compared to those with resolution of PEP in the short term. Long-term implications of persistent
PEP will be important to ascertain.

Introduction: Anastomotic leaks continue to be the Achilles heel of esophago-gastric anastomosis. Advent
of minimally invasive esophagectomy necessitated the incorporation of stapled anastomotic techniques
especially for intra-thoracic anastomosis. Aim of this study is to review a single centre experience of circular
stapled anastomosis during Ivor-Lewis esophagectomy.
Methodology: After IRB approval, patient data was retrieved from prospectively maintained database to
identify patients who underwent Ivor- Lewis esophagectomy with circular stapled (EEA) anastomosis. The
entire group was divided in three equal sequential cohorts (A, B and C) and compared for patient centred
variables. Patients with either cervical anastomosis or hand sewn intra-thoracic anastomosis were excluded.
Results: Seventy five patients (divided into sequential cohorts of 25 patients each) underwent Ivor-Lewis
esophagectomy with circular stapled (EEA 25/28) anastomosis from 20072015. Mean age and BMI did
not differ significantly between the three groups (Age: 63.7 years vs. 66.7 years vs. 64.4 years; BMI: 31.4
Kg/m2 vs. 29.1 Kg/m2 vs. 28.9 Kg/m2). Group A had significantly longer mean hospital stay as compared
with Group B and C (23.7 days vs. 15.9 days vs 14.1 days, p\0.05). There were no significant differences
between three groups with respect to mean post-operative ICU stay (8 days vs. 6 days vs. 5.6 days, p=NS) or
mean operative time (382.9 vs. 374.7 vs. 355.8 min, p=NS). Ten patients (13%) had anastomotic leak; of
these, one patient required redo-anastomosis while rest 9 patients underwent endoscopic interventions. Four
patients underwent endoscopic stenting, three patients received endoscopic washes and two received transnasal wound VAC therapy. There was significant decrease in rate of anastomotic leak with time (8 vs. 1 vs.
1, p=0.004). Procedure was converted to open in 5, 4 and 2 patients in group A, B and C respectively while
1, 4 and 3 patients respectively were electively operated by open approach. One patient in group A had to be
converted to open due to intra-operative stapler malfunction necessitating conversion to hand-sewn anastomosis. There were two in-hospital deaths, one each in group A and C, including one death due to
anastomotic leak (group A).
Conclusion: There is a decrease in rate of anastomotic leaks with experience following Ivor-Lewis
Esophagectomy using EEA stapled anastomosis.

Table 1 .

Fig. 1 .

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P298

P300

Study on Postoperative Dysphagia Following Gastroesophageal

Fundoplication and Response to Endoscopic Dilation

Laparoscopic Gastric Exclusion with Small Bowel Diversion

as Primary Treatment for Complicated GERD

Ambar Banerjee, MD, Taylor Coleman, BS, Daniel McKenna, MD,

Jennifer Choi, MD, Don Selzer, MD, Department of Surgery, Indiana
University School of Medicine, Indianapolis, IN

Cory Richardson, MD, Shawn Roberts, MD, FACS, Timothy

LeMieur, MD, FACS, Howard McCollister, MD, FACS, Paul
Severson, MD, FACS, Minnesota Institute for Minimally Invasive
Surgery

Objective: The objective of our study was to assess -

The incidence of dysphagia in patients who underwent complete or partial gastroesophageal

fundoplication

The effect of esophageal dilation on improvement of dysphagia and recurrence of reflux symptoms

Methods and Procedures: Following institutional review board approval, retrospective chart review of
patients who underwent partial/complete gastroesophageal fundoplication with/without paraesophageal
hernia repair between January 2006 and January 2014 was performed from a prospective database. The
patients charts were reviewed for information on demographics, preoperative work-up, postoperative follow-up and subsequent surgical interventions. The operative reports were reviewed to obtain perioperative
data. Demographics and other baseline patient characteristics were analyzed with descriptive statistics. The
significance of the relationships of the nominal and continuous variables was calculated with t-test or Chisquare test. P-values less than 0.05 were considered significant. Statistical analysis of the data was performed using the SPSS statistical software, version 20.0 (SPSS Inc., Chicago, IL).
Results: Nine hundred and two consecutive patients, with a mean age of 57.814.7 years were included in
the study. Females comprised 71.3% of the population with an average BMI of 29.55.5 kg/m2. Laparoscopic Nissen fundoplication (NF) and laparoscopic paraesophageal hernia repair with NF were performed
in 436 and 190 patients respectively. Laparoscopic Toupet fundoplication (TF) and laparoscopic paraesophageal hernia repair with TF was performed in 10 and 83 patients respectively. 22.9% of the patients
presented for a revisional procedure. The mean operative time was 101.850.9 minutes with an average
length of stay of 2.654.9 days. Postoperative dysphagia was noted in 26.3% patients. However, endoscopic
dilation of the fundoplication was necessitated in 93 patients (10.3%) with persistence of dysphagia in
63.4% of this subpopulation (59 patients). (p\0.01) Occurrence of recurrent reflux symptoms was observed
in 54.5% of the patients who underwent endoscopic dilation (p=0.27). Nissen fundoplication was performed
in 89% of the patients with postoperative dysphagia while the rest had Toupet fundoplication. Dysphagia
was more frequently noted in patients undergoing revisional surgery with complete fundoplication when
compared with partial fundoplication. (p=0.81) The overall rate of subsequent revisional surgery was 35% in
all patients who developed any postoperative dysphagia (p\0.01).
Conclusions: Endoscopic dilation of gastroesophageal fundoplication may provide some relief in patients
complaining of postoperative dysphagia with increased risk of development of recurrent reflux. Revisional
surgery may ultimately be indicated for control of symptoms.

Intro: Roux-en Y gastric bypass (RYGB) was performed for complicated gastro-esophageal reflux disease
(GERD) long before it was considered a weight loss operation. Studies have confirmed resolution of
esophageal ulcerations and strictures after RYGB. Early publications, however, lacked a common term for
this procedure, often referred to as gastric diversion, duodenal diversion, or partial gastrectomy with roux en
Y diversion. RYGB became known solely as a weight loss procedure as improved medical therapy for
GERD diminished the necessity of RYGB for reflux. The current preferred anti-reflux procedure, laparoscopic gastric fundoplication, has reported failure rates of up to 22%. Additionally, co-morbidities such as
esophageal motility disorders, dysphagia, diabetes, gastroparesis, and obesity make fundoplication less
effective or even contraindicated. In some centers RYGB continues to be recognized as an excellent and
permanent treatment for GERD. However, as RYGB is acknowledged only as an obesity operation by
coding language and payers, many non-obese patients are left without any options after failed
fundoplication.
Materials and Methods: PubMed search performed using terms: gastric diversion, esophagitis,
gastric bypass for GERD, gastric resection for esophagitis, and roux-en Y duodenal diversion.
Twenty-two studies were reviewed for: type of study, time period of study, operation performed, number of
patients, length of roux limb, length of follow up, prior anti-reflux procedures, and improvement of
symptoms. Additionally, we are currently analyzing the same variables in 50 non-morbidly obese patients
who have undergone this procedure (termed Laparoscopic gastric exclusion with small bowel diversion),
at the Minnesota Institute for Minimally Invasive Surgery.
Results: A review of these studies, in addition to our own experience shows that:
1. RYGB for complicated reflux has been shown to be safe with 517 years of follow up.
2. RYGB is effective for both the symptoms and complications of GERD regardless of BMI.
3. RYGB in the non-morbidly obese does not cause weight loss below normal BMI.
Conclusion: The literature supports the argument for RYGB to be the indicated operation for complicated
GERD in the morbidly obese, for the less than morbidly obese, and for patients with failed fundoplication
regardless of weight. A definitive procedure exists to eliminate or drastically reduce symptoms and complications of GERD, and it should not be withheld from patients simply because it is also a highly visible
procedure performed on the morbidly obese for weight loss.

P299
P301
Laparoscopic Gastroplasty and Dor Fundoplication for Gastric
Sleeve Stenosis with a Proximal Dilated Sleeve
1

2 1

Luciano Poggi, MD , Daniel Pita, MD , Luis Poggi, MD , Oklahoma

University Health Science Center, 2Clinica Anglo Americana
Introduction: Obstructive symptoms and Gastroesophageal reflux (GERD) after Gastric sleeve remain
severe problems. There is no consensus on the best management of this condition, some author have
advocated endoscopic versus surgical management specially in refractory cases, most of the time proceeding
with gastric bypass. Most of the patients present with dilated proximal segment or neofundus that seems
to play a role in patient symptoms, specifically in reflux. The objective of this study is to describe a surgical
option to manage the gastric sleeve stenosis and the dilated proximal sleeve performing a gastroplasty and a
Dor fundoplication when gastric bypass is not option and ballon dilatation has failed.
Methods: We present 3 patients referred to our institution due to severe GERD associated occasionally with
nausea, vomiting and weight loss after Sleeve Gastrectomy. Extensive preoperative evaluation was obtained
including Abdomen and Pelvis CT scan, esophagogastroduodenoscopy, upper gastrointestinal series, 24 hrs.
Esophageal Ph study and manometry. Prior to surgery all patients underwent endoscopic balloon dilatation
up to 35mm, however resolution of symptoms would be temporary. All patients underwent laparoscopic
Gastroplasty along the area of stricture, hiatal hernia repair and a Dor fundoplication.
Results: Patients presented between 3 to 12 months after sleeve gastrectomy. The mean body mass index
pre and postoperative were 31 and 20 kg/m2 respectively. None of the patients had GERD symptoms prior
to Gastric sleeve. All three patients were found to have a small hiatal hernia. None of our patients had
esophageal dismotility.
A standar vertical incision was performed along the stricture segments to subsequently close it transversely.
The stricture was found consistently in the proximity of the incisura angularis. The length of the stricture
was as an averaged of 5 cm. Hiatal hernia was repaired primarily and reinforced with biologic mesh. The
proximal dilated segment was use to create an anterior fundoplication. Operative time was an average of 180
minutes.
Postoperatively patients have been follow at least 6 months (618months), 2 patients had resolution of
GERD symptoms and one significant improvement. All patient have gain weight.
Conclusion: Laparoscopic gastroplasty and Dor fundoplication is a feasible and safe option for patient with
Gastric sleeve stenosis and severe reflux associated with a dilated proximal sleeve. This option should be
consider in patients in which a seromyotomy is not able to be perform or morbidity of converting to gastric
bypass or gastric resection with another type of reconstruction is not desirable.

123

Searching for a Suitable Approach for Laparoscopic Inguinal

Hernia Repair: Inicial Experience
Ezequiel Sadava, Martin Galvarini, Belen Castro Fuentes, Romina
Reino, Florencia Ocariz, Francisco Schlottmann, Hospital Aleman
of Buenos Aires
Introduction: Since its introduction laparoscopic inguinal hernia repair has obtained worldwide acceptance.
Although totally extraperitoneal (TEP) technique offers no-entry into abdominal cavity with similar outcomes compared to transabdominal preperitoneal (TAPP) technique, the latter one is preferred by most of
the surgeons. In the era of tailored treatments, we aimed to evaluate whether TEP is more adequate approach
in the treatment of inguinal hernia.
Methods and Procedures: From June 2012 to February 2015 all charts of consecutive patients underwent to
laparoscopic inguinal hernia repairs were revised. Patients who had clinical history of pelvic surgeries and
femoral hernias, and also those with less than 6 months of-follow-up were excluded. Demographics,
operative features and post-operative complications were analyzed comparing totally extraperitoneal (TEP)
and trans-abdominal preperitoneal (TAPP) techniques. Also mid- and long-term follow-up was evaluated
with focus in hernia recurrence and chronic pain.
Results: A total of 297 laparoscopic inguinal hernia repairs were included in the study: 50 (17 %) TEP and
247 (83 %) TAPP repairs with synthetic prosthesis. There was no difference in gender, age, BMI and ASA
score between groups (p=NS). The mean defect size was 4 cm in TEP and 4.5 cm in TAPP (p=NS). All TEP
repairs were performed by the same surgeon. The rate of peritoneal tears was 15 % and there was no
conversion to TAPP. Length of hospital stay was similar between groups (TEP: 0.4 days vs TAPP: 0.6 days,
p=NS). No difference was found in thirty-day postoperative complications: TEP: 6 % (3 patients) vs TAPP 3
% (7 patients), p=NS. With a mean follow up of 18 (630) months, the incidence of recurrence was 2 % in
both groups (p=NS) and 1 patient in TAPP group had chronic pain ([ 6 months).
Conclusions: Both laparoscopic hernia repairs are safe and effective procedures. In this series we failed to
find differences in postoperative outcomes when comparing TEP and TAPP techniques. Prospective
investigations would provide new insights in this controversial issue to make the right choice for the most
suitable surgical technique.

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P302

P303

Quantitative Measures of Visceral Adiposity and Early

Postoperative Complications Following Complex Abdominal Wall
Reconstructions

How Many Cases Do You Need to Achieve Competence

and Proficiency in Total Extraperitoneal Groin Hernia Repair?

Joshua S Winder, MD, Alexander J Shope, BS, Salvatore Docimo, Jr.,

DO, Eric M Pauli, MD, Penn State Milton S Hershey Medical Center
Introduction: Obesity is a risk factor for complications after hernia repair, but the contribution of visceral
adiposity to perioperative hernia morbidity is unclear. Quantitative analysis of the visceral to subcutaneous
fat ratio (VSFR) using computed tomography (CT) based measurements has been proposed to be a more
effective means of assessing obesity related morbidity than simple body mass index (BMI) calculations
alone. The objective of this study was to examine the effect of visceral obesity on post-operative morbidity
in patients undergoing abdominal wall reconstruction.
Methods: We performed a retrospective review of a prospectively maintained database of patients who
underwent posterior component separation with transversus abdominis release (PCS/TAR) from 20122015.
All patients who had a CT scan of the abdomen and pelvis within 30 days of surgery were included in the
study. Patient demographics, medical co-morbidities, operative details, complications and length of stay
were recorded. Visceral and subcutaneous fat areas were obtained from postoperative CT scans using
DICOM viewing software (Osirix 6.5, Pixmeo) from a single axial slice at L4L5 intervertebral space and
used to calculate the VSFR. The CT attenuation level to delineate the regions of adipose tissue was set using
-190 to -30 Hounsfield units. An elevated VSFR, indicating a larger amount of visceral fat, was defined as
C 0.4.
Results: Thirty-nine patients were identified; median age 56 years, ASA score 2, BMI 32kg/m2, 60%
female. The median VSFR was 0.46. Twenty-seven (69%) patients had VSFR C 0.4. When comparing
baseline characteristics of gender, age, ASA, BMI, hernia grade, hernia area, and presence of comorbid
conditions such as diabetes mellitus and pulmonary disease there was no significant difference between
patients with elevated VSFR to those with normal VSFR. When comparing postoperative complications
including surgical site infections (superficial/deep), seromas, hematomas, skin-level dehiscence, organ space
infections, venous thromboembolism, ileus, respiratory failure, cardiac events, and need for mechanical
ventilation postoperatively, there was no significant difference between groups.
Conclusions: Our results failed to show a significant difference in postoperative morbidity based on VSFR,
although this may be due to our small numbers of patients or the lower rates of post-operative events after
PCS/TAR. Interestingly, 69% of patients in the study had an elevated VSFR. It is unclear whether this
finding is due to the presence of a hernia or whether high VSFR is an independent predictor for hernia
formation.

Hesham M Souka, MD, FRCS, MBBCh, Amina Hospital, Ajman,

UAE
Introduction:

My aim is to present the learning curve of total extraperitoneal groin hernia repair in a prospective registry
of 462 cases by a single surgeon over 9 years.
Methods: Prospective data collection of age, gender, ASA status, occupation of patient, type of hernia found
during the operation, complications, and operative time of the procedure were recorded. Follow up and
return to normal activities were also recorded.
Results: Mean age was 59 years (2088y), 97% were males. The median ASA status was II. 42% of patients
were retired, 5% unemployed, 30% had heavy manual jobs and 23% had a mixed office and/or light manual
job.
Most of the cases were planned as day cases; this was achieved in 87% of the patients. Of all the hernia sides
operated upon, 11% were recurrent hernias.
Operative findings showed 11% of the cases were bilateral hernias, 40% of hernias were direct, 56% were
indirect. 4% were femoral and Spigelian hernia. Significant lipoma of the cord was encountered in 25% of
the cases.
Mean operative time of unilateral hernia was 26 minutes (range 1260 minutes).
Recurrence rate was 1%. Seroma formation (19%) was the commonest complication. Other complications
include acute urinary retention 6%, return to theatre for port site bleeding in one case and persistent groin
pain in 3% of the patients.
Return to normal activity took an average of 1.9 weeks (range 18 weeks).
Return to car driving for drivers reported at 2.5 weeks (range 18 weeks).
Conclusion: Operative time is a useful surrogate measure for competence and proficiency. Number of
procedures performed per year as well as a record of complications should also be considered. Once
competence achieved, the procedure is safe, consistent and carries benefit to the patients. Competence is
related to total number of procedures performed within a year (probably 20 are needed), Proficiency is
usually achieved after performing 100 procedures.

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Laparoscopic Assisted Recti Diastasis Approximation (LARDA),

Experience and Outcome of a Novel Technique

A New Intraoperative Laparoscopic Examination for Detecting

Inapparent Contralateral Hernia During Open Inguinal Hernia
Repair

Eva Lourdes, Jesse Hu, Wee Boon Tan, Davide Lomanto, Prof,
Minimally Invasive Surgery Centre, Department of Surgery, National
University Health System, Singapore
Introduction: Rectus diastasis is common in women post pregnancy and the indications for surgery are
controversial. However, it is reasonable to repair it with an umbilical hernia concurrently. Many variations
of abdominoplasty have been described but little has been published on the concurrent laparoscopic repair of
recti diastasis and umbilical hernia. Here, we describe a novel laparoscopic technique for concurrent repair
of both problems.
Methods: Under general anaesthesia, the patient is placed in the supine position. A 10 mm port is placed in
the right flank via Hasson approach and a 5 mm port is placed on each side of the first port. Diagnostic
laparoscopy is performed and then reduction of the hernia contents. Subsequently, pneumoperitoneum is
reduced and the diastasis is plicated laparoscopically using a suture passer with transfacial sutures placed via
stab incisions along one side of the diastasis and extra-corporeally tied. Reduction of the divertification is
confirmed by manual pressure on the anterior abdominal wall. Then, the hernia defect is reinforced with
mesh placement and anchored using transfascial sutures and absorbable tacks. Patients were discharged with
abdominal binder for a period of 1 month following surgery.
Results: Eight patients underwent the repair over a 2 year period in a tertiary institution. They were all
mothers with mean age of 37 years (n:3150). The main presentation was an abdominal lump secondary to
the umbilical hernia and rectus diastasis. The mean operation time was 90 minutes (n:80105). One patient
underwent single port repair. The median length of stay post-operatively was 2 days (n:13). All patients
were followed up for minimum of 3 months. No complications of seroma or infection. All patients were
satisfied with the cosmetic outcome.
Conclusion: Our technique of concurrent management of rectus diatasis and umbilical hernia laparoscopically is feasible and reproducible with good outcomes.

123

Hideto Oishi, MD, PhD, Toshihiko Mori, MD, Mimi Okano, MD,
Takeshi Ishita, MD, Masayuki Ishii, MD, Takayuki Iino, MD,
Hidekazu Kuramochi, MD, PhD, Shunsuke Onizawa, MD, PhD,
Eiichi Hirai, MD, PhD, Mie Hamano, MD, PhD, Satoshi Katagiri,
MD, PhD, Tsutomu Nakamura, MD, PhD, Tatsuo Araida, MD, PhD,
Division of Gastroenterological Surgery, Department of Surgery,
Yachiyo Medical Center, Tokyo Womens Medical University
Introduction: We have devised a technique by which we can detect inapparent contralateral hernia(s) laparoscopically in patients undergoing open inguinal hernia repair without general anesthesia, and we
evaluated the usefulness of the technique by reviewing cases in which the laparoscopic technique has been
applied. Although prone abdominal computerized axial tomography (CAT) as a preoperative screening is
generally very effective in identifying not only the main inguinal hernia but also any inapparent hernia, not
all inapparent hernias are found by means of preoperative CAT. During laparoscopic inguinal hernia repair,
inapparent hernia lesions are easy to find, so we select laparoscopic repair when circumstances allow.
However, general anesthesia is required for laparoscopic repair, and thus it is not applicable to all patients.
Some must undergo open repair.
Methods and Procedures: Between January 2007 and December 2014, we repaired 688 inguinal hernias in
571 patients. Two hundred and ninety-six (51.8%) underwent laparoscopic repair, and 275 (48.2%)
underwent open repair. As the years progressed, the percentage of laparoscopic repairs increased. In 2014,
among 76 total patients, we performed laparoscopic repair in 59 (77.6%) and open repair in 17 (22.4 %).
Because 11 of these 17 patients had serious risk factors, such a chronic obstructive pulmonary disease and/or
cardiac failure, general anesthesia was contraindicated, so the repair was performed under lumbar anesthesia. Open repair is performed without pneumoperitoneum. We used a laparoscope intraoperatively in
these patients to find inapparent contralateral hernias.
The laparoscopic inspection was carried out after the sac of the main hernia was cut open. A hook was
inserted by its tip into the abdominal cavity via the hernia orifice and then used to lift the abdominal wall. In
this way, we created a space through which we could observe the contralateral inguinal area. A laparoscope
was then inserted to search for any inapparent hernia.
Results: In 6 of 11 patients under lumbar anesthesia, obtaining a laparoscopic view of the contralateral
inguinal area was quick and easy. Inapparent contralateral hernias were found by this method in 2 of 6
patients, and were repaired at the same time additionally. No complications resulted from this simple
procedure.
Conclusions: Our intraoperative laparoscopic inspection technique appears to be very effective for detecting
inapparent contralateral hernia(s) in patients undergoing open hernia repair without general anesthesia. We
expect the technique to prevent the need for postoperative contralateral hernia repair in most such patients.

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Surgeon Performed Rectus Blocks Reduce Same Day Admission

Rates After Laparoscopic Ventral Hernia Repairs, a Case Series
of 52 Patients

Fixation Tacks Add Significant Weight to Hernia Repair

Matthew Kasulke, MD, David Ryan, MD, Ibrahim Daoud, MD,

St. Francis Hospital
Overview: Analgesic nerve blocks reduce post-operative opioid use while fostering patient mobilization and
comfort. We performed rectus sheath blocks under laparoscopic vision during ventral hernia repairs. Traditionally this procedure requires 23 days of hospitalization for analgesia. Our technique facilitates same
day discharge and reduces OR time since it is performed intra-operatively without special equipment and
personnel (i.e. ultrasound/anesthetists).
Methods: All patients undergoing laparoscopic ventral hernia repair with mesh from 1/2015 to 8/2015 were
included. Fascia was not closed and rectus blocks were performed before affixing mesh. Age, race, sex,
weight, BMI, ASA classification, ventral hernia type, comorbidities, admission rate, length of stay, readmission rates, procedure length, recovery room time, adhesiolysis amount, mesh type, device for mesh
fixation, intra-operative analgesia, rectus block anesthesia amount/type, recovery room analgesia, and
postoperative complications were recorded.
Results: 52 patients were included with a median age of 50.5 years (53.8% female). Median weight and
BMI were 86.5kg and 29.51 kg/m2. 11.5% of subjects were ASA 1, 80.8% ASA 2, 5.8% ASA 3, and 1.9%
ASA 4. 3 patients were admitted from recovery room and were ASA 2. One patient was re-admitted for
biliary colic 21 days post operatively. Two patients went to the ER 4 days out and were discharged from
there (nausea/chest pain).
Median length of procedure was 42 minutes and median recovery room stay was 109.5 minutes. All
employed the SorbaFix device for mesh fixation except for two in which; 1) ProTack and 2) SorbaFix plus
Tisseel were used. Mesh was 15 x 20cm Ventralight (n=3), 20 x 25cm Ventralight (n=4), 11.4cm Ventrio ST
(n=40), or 11 x 14cm oval Ventrio ST (n=5).
Intraoperative analgesia ranged from 100mcg fentanyl administered once to fentanyl, 1mg dilaudid, 30mg
Toradol, and 1000mg Ofirmarev administered per operation.
51 of 52 patients were given the rectus block: 30ml of 0.5% Bupivacaine with epinephrine (n=42) or 30ml of
0.25% Bupivacaine with epinephrine (n=9).
Recovery room analgesia ranged from none to 1.5 mg dilaudid and 5mg oxycodone. 3 received 30mg
Toradol and 6 received Norflex 30mg.
Conclusion: Our study is limited by low sample size and its non-blinded, single surgeon/institution potential
biases. The technique is effective, inexpensive, and efficient. Similar anesthetic blocks like the transversis
abdominus and pediatric rectus blocks are proven clinically. Our goal is to expose a new technique that may
improve analgesia and decrease admission rates after this painful operation. We hope our experience
prompts further investigation.

Thomas Cook, Karl A LeBlanc, MD, MBA, Our Lady of the Lake
Regional Medical Center
Introduction: The purpose of this study is to assess the amount of foreign body introduced by different
hernia mesh fixation devices in relation to hernia meshes. While there is an abundance of scientific data on
HW and LW meshes and their impact there is no corresponding data on HW and LW hernia tacks (the other
major source of implanted foreign body in hernia repair). In the majority of the LVHR procedures 3060
tacks are implanted. This study was undertaken to evaluate the weight of foreign material of the deployed
tacks in relation to hernia meshes. Additionally the study will analyze the different fixation devices based
upon their strength of fixation as it relates to foreign body ratio.
Methods and Procedures: The total weight of 45 tacks from each type was calculated and compared to the
weight of several available hernia meshes of the size 15 X 20cm, the meshes weight was measured or
calculated based on their density and manufacturer data.
In addition sheer force strength of each hernia tack was measured, (n=50) on a porcine abdominal muscle
wall sample.
Although not fully available at the time of this abstract submission, comprehensive tack weight and fixation
measurements will be presented on the majority of marketed fixation devices; the measurement will be done
according to acceptable testing protocols.
Results: The weight of various meshes is shown in the Table 1. Tacks, in particular, helical & screw-like
tacks are in many cases the main source of foreign body in hernia repair.
Fixation strength to foreign body suggests wide variation in this factor between different fixation products.
The suture-like design has a fixation strength of 3[N/mg] compared to the screw-like design, which is
approximately 0.5[N/mg]. This suggest that suture-like devices are stronger per same amount of foreign
body than screw-like devices.

Conclusion(S): it appears that utilizing a light weight hernia doesnt necessarily correspond to light weight
hernia as tacks are responsible to significant amount of implanted foreign, sometimes representing more than
half of the overall implanted foreign body.

Table 1 .

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Minilaparoscopic Inguinal Hernia Repair (M-TAPP) with 5mm

Laparoscope and 2mm Grasper: An Alternative to Traditional
TAPP

Tumescent Anesthesia for Totally Extraperitoneal (TEP)

Laparoscopic Inguinal Hernia Repair

Atsushi Urakami, MD, Munenori Takaoka, MD, Jiro Hayashi, MD,

Kaori Shigemitsu, MD, Kazuhiro Yoshida, MD, Yoshio Naomoto,
MD, Department of General Surgery, Kawasaki Medical School
Introduction: Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is
associated with a decrease in postoperative pain, shortened hospital stay, and decrease in
chronic pain. However, recent advances in minimally invasive surgery aimed at diminishing number of ports and incision size have led to the development of reduced port
surgery (RPS). RPS has an increased level of complexity and requires a higher level of
surgical skill compared to traditional laparoscopic surgery. We developed minilaparoscopic
inguinal hernia repair (m-TAPP) in an attempt to further decrease postoperative pain and
improve cosmetic outcome. It employs smaller instruments and has been associated with
potentially decreased postoperative pain and improved cosmetic outcome, and overall
patient satisfaction in elective cases of TAPP.
Methods:The study is a retrospective review of consecutive elective TAPP performed by
three surgeons at a community teaching hospital over 24 months. All surgeries were performed using a 5mm trocar for the umbilical port with 5mm laparoscope, the right lateral
port, and 2mm trocars for the left lateral port with 2mm grasper in standard TAPP style.
After reduction of the hernia sac and dissection of the preperitoneal space, we placed
polyester mesh (Parietex folding mesh), which can be inserted via 5mm port, with staple
(Absorbatack) fixation. The peritoneum was closed with 30 Polysorb in continuous
sutures.
Results: 51 patients underwent m-TAPP were retrospectively investigated. The mean
operative time was 83.2 min for unilateral and 115.4 min for bilateral hernias. There was no
conversion to open repair. Ten patients (20%) used postoperative analgesics. The mean
length of hospital stay was 2.2 days. Regarding intraoperative complications, we observed
no bowel injuries or major vessel injuries. Postoperative complications occurred in 1 patient
(2%), who had a postoperative hemorrhage which required re-operation. There was no
incidence of chronic pain or mesh infection.
Conclusions: m-TAPP was a safe and useful technique for inguinal hernia repair. Compared with standard TAPP, m-TAPP had similar operative times and similar length of stay.
Large prospective, randomized controlled trials will be required to establish the benefit of
m-TAPP.

Yoshihide Chino, PhD, Masaki Fujimura, PhD, Isao Sato, PhD,

Makoto Mizutani, PhD, Tomotake Tabata, MD, Tomoyuki Tagi, PhD,
Shigeyoshi Shimaoka, MD, Shoichi Takayama, PhD, Minoru IIda,
PhD, Daiich Towakai Hospital
Tumescent anesthsia is known to be a safe and feasible procedure for TAPP laparoscopic
inguinal hernia repair as reported. We use this type of anesthesia for TEP laparoscopic
inguinal hernia repair (t-TEP). The aim of the current study is to show the surgical techniques utilized, and the efficacy of t-TEP.

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A Hybrid Technique for Ventral Hernia Repair: Open Fascial
Closure with Laparoscopic Assisted Mesh Placement
Vadim Meytes, DO, Aaron Lee, DO, Ryan Pinnell, DO,
Yulia Rivelis, Michael Timoney, MD, NYU Lutheran Medical Center
Introduction: A ventral or incisional hernia is one of the most common issues that general
surgeons face annually in the U.S. At our institution, one surgeon has been performing a
unique repair of intermediate-sized hernias by combining open and laparoscopic approach
over the last several years.
Presentation: Here we present a retrospective case series of 19 patients that underwent a
limited incision primary hernia repair followed by laparoscopically-assisted underlay mesh
placement. End results analyzed intra-operative complications, length of stay, recurrence
rate, seroma formation, and skin infection.
Results: Of the 19 patients, 1 had an early recurrence of the hernia. 3 patients had an early
surgical site infection noticed during the 1 week follow-up appointment. None of the
patients developed seromas.
Conclusion: A hybrid technique is a safe alternative method when repairing intermediatesized ventral hernias, with a low recurrence rate and minimal post-procedural pain.

123

Tailored Laparoscopic Approach in Large Inguino- Scrotal

Hernias: An Institutional Review
Eva Lourdes, Rakesh Gupta, Siau Wei Tang, Jesse Hu,
Wee Boon Tan, Davide Lomanto, Prof, Minimally Invasive Surgery
Centre, Department of Surgery, National University Health System,
Singapore
Introduction: Since 2 decades laparoscopic hernia repair has gained a key role in
uncomplicated inguinal hernia surgery with advantages showed by several trials and
guidelines. However, its role in complicated inguinal hernia as incarcerated, obstructed and
inguino-scrotal is still debatable even though a clear role as diagnostic tools is claimed. In
particular, case of large inguino-scrotal evokes vehement objections to a laparoscopic
procedure because of the anticipated problems and complications in dissecting the extended
hernia sac even though a posterior approach has been advocate as repair of choice for
complicated cases. In this study, we reviewed our series of patients undergoing Endolaparoscopic repair of large inguino-scrotal hernias in a limited period of time.
Method: Between March 2013 and July 2015, 50 patients with inguino-scrotal hernias
underwent laparoscopic inguinal hernia repair. Patient demographics, hernia characteristics,
operating time, surgical technique, conversion rate, intraoperative and postoperative complications and recurrence were recorded, measured and analyzed using MS Excel software.
Result: 50 patients who underwent laparoscopic inguinal hernia repair were recorded, 47
patients underwent total extraperitoneal (TEP) inguinal hernia repair and 3 patients
underwent transbdominal pre-peritoneal (TAPP) inguinal hernia repair. 26 patients had
unilateral hernia and 24 patients had bilateral hernias. The mean age was 45 years old
(range 1872 years). The mean operation time was 74 min (range 46102 min) for unilateral hernia and 116.5 mins (range 55178 mins) for bilateral hernia. Three patients (6%)
required a combined open surgery to transect the incarcerated omentum. There was no
mortality. Morbidity was limited to seroma formation in 13 (26%) patients, 2 patient of the
combined laparoscopic-open approach had wound infection treated with dressing and
antibiotics, and 1 had orchitis. Mean Follow up was 26 weeks (range 152 weeks). There
were no recurrences (4.8%). All patients were discharged within 23 hours
Conclusion: We conclude that laparoscopic TEP can be safely employed for the treatment
of complicated inguinal hernias as inguino-scrotal; surgical experience in endolaparoscopic
hernia repair is mandatory with tailored technique in order to reduce to minimum morbidity
and to achieve good clinical outcomes with acceptable recurrence rates.

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First Human Experience with a Hybrid Biologic and Synthetic

Mesh: ZenaproTM Hernia Repair Device for Ventral Hernia
Repair

Early Outcomes of Self-Adhering vs. Conventional Polyester

Mesh in Laparoscopic Inguinal Hernia Repair

Kevin El-Hayek1, Melissa Phillips2, Jin Yoo3, Eric Pauli4, James

Bittner5, Matthew Kroh1, 1Cleveland Clinic, 2University
of Tennessee, 3Duke University, 4Pennsylvania State University,
5
Virginia Commonwealth University
Introduction: The management of patients with complex hernias, often with multiple recurrences
and comorbidities, is challenging and often requires abdominal wall reconstruction or closure with
a bridged repair. Previous hernia repair devices include permanent synthetic with or without
barriers, absorbable synthetic, and biologic. ZenaproTM, a novel hernia repair device, combines the
elements of biologic grafts with synthetic material to create a device that is available for use in
these challenging cases. The objective of this report is to analyze interim results of the first patients
who underwent ZenaproTM implantation for hernia repair.
Methods and Procedures: A prospective, multicenter, single-arm study (NCT01784822) has
completed recruitment of 63 patients to study the clinical outcomes of ventral hernia repair with the
ZenaproTM Hybrid Hernia Repair Device. This graft is comprised of seven layers of porcine small
intestine submucosa (SIS) covering a core of open-pore lightweight polypropylene. Inclusion
criteria were broad and included patients with primary or recurrent hernias who required the
addition of a reinforcement or bridging material to perform hernia repair. The primary study
endpoint was hernia recurrence at 12 months, with secondary endpoints to measure device related
occurrences.
Results: Sixty-three patients completed at least 6 months follow-up (range 612 months). 46%
were male and 79% were Caucasian. Mean age was 54.8 10.9 years (range: 3381) and Body
Mass Index was 34.5 7.8 kg/m2 (range: 17.557.5). Significant comorbidities included smoking
history (57.1%), hypertension (63.5%), and insulin-dependent diabetes (25.4%). The majority of
patients (53/63, 84%) had previous abdominal surgery. Laparoscopic repair was performed in 38/63
(60.3%) of patients with conversion to open in six cases (9.5%). Graft position was intraperitoneal
onlay (IPOM) in 44/63 (69.8%). Component separation was performed in 22 patients (34.9%).
Complete fascial closure was achieved in 74.6%. To date, there have been no device infections and
4 (6.3%) recurrences. Post-operative seroma occurred in 28.5%, though only one patient required
aspiration. Other complications included ileus or bowel obstruction (4.7%), surgical site infections
[C3] (3%), hematoma (1.5%), and wound dehiscence in (1.5%).[C4] There was one death due to
fulminant C. difficile infection after antibiotic therapy for post-operative pneumonia.
Conclusions: ZenaproTM Hybrid Hernia Repair Device offers surgeons a durable and biocompatible alternative for challenging hernia cases where previous operations and multiple
comorbidities are common. Interim follow-up of these patients demonstrates an acceptable recurrence and complication rate. Further analysis will be completed after 12 month follow-up.

Shani Belgrave, MD, Andrew S Wright, MD, Zoe E Parr, MD,

Hinojosa Marcelo, MD, Giana Davidson, MD, University
of Washington
The need for mesh fixation during laparoscopic inguinal hernia repair is controversial. Many
surgeons use fixation devices to prevent mesh migration and hernia recurrence despite evidence
suggesting that mesh fixation is unnecessary and post-operative pain may be related to the use of
tacks. Recently we adopted a self-adhering mesh designed for laparoscopic placement without tack
fixation (Laparoscopic Progrip, Medtronic). There have been no known early clinical outcome
comparisons between conventional mesh and self-adhering mesh for laparoscopic hernia repair.
Methods: All laparoscopic inguinal hernias performed at a single academic institution by 4
experienced laparoscopic hernia surgeons between 1/1/14 and 9/8/15 were retrospectively analyzed
through chart review. Self-adhering mesh was introduced in 8/14 with implementation over the
following months. Costs of mesh and tackers were obtained from hospital materials management.
Data was analyzed using SPSS.
Results: There were 45 inguinal hernia repairs performed using flat sheet self-adhering mesh, and
46 using conventional polyester mesh in a pre-shaped configuration (anatomic Parietex, Medtronic). Median time from surgery to date of review was 449 days for conventional, compared to
206 for self-adhering. Demographics were similar (age, sex, BMI, type of hernia) between groups
(ns). Tacks were used in 3/45 self-adhering (6.7%) and 38/46 conventional (82.6%). In the selfadhering group there were 19 bilateral hernias and 12 recurrent hernias repaired, compared to 14
and 6 in the conventional group, respectively (ns). 2 repairs in each group were performed as
TAPP, with the remainder being TEP. Operative time was median 9534min for self-adhering and
9437min for conventional (ns). In the self-adhering group there were 3 spermatic cord hematomas, 4 seromas, 2 episodes of urinary retention, 1 scrotal swelling, and 2 patients with pain lasting
[ 1 month. In the conventional group there were 2 hematomas, 1 scrotal swelling, and 1 urinary
retention. 5 patients had pain lasting [1month, with 1 requiring reoperation for a retained cord
lipoma. There was 1 early recurrence in a large pantaloon hernia repaired with conventional mesh
and no tacking. Unit costs were $419/tacker, $314/self-adhering mesh and $128/conventional
mesh. Given an overall bilateral hernia rate of 36% and consistent tacker use, switching to selfadhering mesh is estimated to save $3,552/year.
Conclusions: Self-adhering mesh is cost-effective when eliminating the use of tacking devices.
Operative times and early outcomes are similar to conventional mesh. Long-term follow-up is
needed to analyze recurrence, clinical outcomes, and rates of chronic pain.

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Multi-Modal Pain Management in a Clinical Quality

Improvement Program for Laparoscopic Ventral/Incisional
Hernia Repair

Early Outcomes of Adhesix Mesh Compared to a Variety

of Mechanically Secured Meshes for Abdominal and Inguinal
Hernias

Bruce Ramshaw1, Jonathan Dean2, Andrew Gamenthaler2,

Michael Fabian2, 1University of Tennessee, Knoxville, 2Halifax
Health

Y Viswanath, Mr, Kevin Etherson, Mr, Anil Reddy, Mr, James Cook
University Hospital

Background: Patients undergoing laparoscopic ventral/incisional hernia repair can have significant
post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain
due to CO2. In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was
begun and multi-modal pain strategies were initiated over time.
Methods: CQI tools were applied for consecutive patients who underwent laparoscopic ventral/
incisional hernia repair from June 2012 through March 2015 (33 months). Initiatives for improved
patient care during this period included the administration of a transversus abdominis plane (TAP)
block as a part of a perioperative multi-modal pain strategy in an attempt to minimize somatic pain
and a low pressure pneumoperitoneum system in an attempt to minimize visceral pain from CO2.
Outcome measures to assess pain and short-term recovery were collected and analyzed.
Results: One hundred and twelve patients who had a laparoscopic ventral/incisional hernia repair
were included in the analysis. Fifty patients had no TAP block and had conventional insufflation at
15 mmHg. Outcomes for this group included an average time in PACU of 168.4 minutes (0426),
an average length of stay of 4.4 days (019), an average use of opioid morphine equivalents in
PACU of 11.0 (041) and an average total use of opioid morphine equivalents of 163.6 (01019.3).
Forty-two patients had a TAP block with a long-acting local anesthetic and conventional insufflation at 15 mmHg. Outcomes for this group included an average time in PACU of 158.4 minutes
(131434), an average length of stay of 3.9 days (017), an average use of opioid morphine
equivalents in PACU of 9.8 (018.3) and an average total use of opioid morphine equivalents of
146.9 (01714.1). Twenty patients had a TAP block with a long-acting local anesthetic and a low
pressure pneumoperitoneum system with standard pressure of 8 mmHg. Outcomes for this group
included an average time in PACU of 91.1 minutes (36212), an average length of stay of 1.5 days
(05), an average use of opioid morphine equivalents in PACU of 5.3 (028.3) and an average total
use of opioid morphine equivalents of 35.6 (0138.3).
Conclusion: Implementation of CQI program including TAP blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients undergoing laparoscopic
ventral/incisional hernia repair was associated with decreased PACU time, decreased length of stay
and less opioid use in PACU as well as for the entire hospital stay.

Introduction: Recent advances in hernia surgery are focussed towards tension free atraumatic
fixation and self-adherence of the mesh. We report a single surgeons experience with the Adhesix
 self adherent mesh in comparison to a variety of other mechanically self-adherent & sutured
meshes during 2014.
Methods: A prospective consecutive cohort database of single surgeon experience of abdominal
wall mesh hernia repair during 2014. Data was extracted for any patient fulfilling the inclusion
criteria: Presence of an inguinal or abdominal wall hernia clinically or on ultrasound imaging, and
undergoing a mesh repair (laparoscopic- TAPP or open) during 2014. Exclusion criteria: absence of
peritoneal sac at time of surgery, or repair without a mesh.
Results: 66 patients (60 male, 6 female) with a median age of 53 years [SD 15] underwent 77
hernia mesh repair procedures during 2014. 58 were for inguinal hernia repairs and 19 for
abdominal wall hernia repairs. 39 patients (36M, 3F, median age 54 [SD 14.8]) had repair with an
Adhesix mesh (Group A). The remaining 27 patients (24M, 3F, median age 50 [SD 14.7]) had
repair with 6 different varieties of mesh for either open abdominal wall hernia or Laparoscopic
incisional or inguinal hernia repairs. The Adhesix group A, consisted of 44 hernia repairs; 3
primary trans-abdominal pre-peritoneal (TAPP) inguinal repairs, 38 open primary inguinal repairs,
1 primary laparoscopic ventral repair, and 2 primary open ventral repairs. Group B, consisted of 33
hernia repairs; 11 primary TAPP, 2 recurrent TAPP repairs, 4 primary open inguinal repairs, 16
other abdominal wall hernia repairs. Anaesthetic recovery time was 38 minutes [SD 15.6] in the
Adhesix group A and 38 minutes [SD 10.0] in group B (P=0.88). Duration before discharge was
also similar at 8 hours versus 7 hours respectively (P=0.68). The overall incidence of short-term
adverse events were similar at 8 (21%) in the Adhesix group A, and 6 (22%) in group B. There
was a significantly reduced incidence of severe post-operative pain in the Adhesix group A (0%)
versus group B (11%) [ P =0.03]. There have been no short-term recurrences in either group to date.
Conclusions: The study demonstrates that a tension free atraumatic fixation self-adhering mesh
such as Adhesix, appears to have a similar safety profile to a variety of other meshes with
assosciated advantage in reduction of severe post-operative pain. Longer-term prospectively
assessed outcomes of hernia recurrence rates & safety profiles with these new self-adhesive meshes
are required

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Impact of Opioid Use on Outcomes After Laparoscopic Ventral

Hernia Repair

Two Cases of Broad Ligament Hernia of the Uterus Successfully

Treated by a Laparoscopic Single-Site Approach

Bruce Ramshaw1, Jonathan Dean2, Andrew Gamenthaler2, Michael

Fabian2, 1University of Tennessee, Knoxville, 2Halifax Health

Katsuhiro Tomofuji, MD, Shinsuke Kajiwara, MD, Kenzo Okada,

MD, Kenji Nedu, MD, Jyota Watanabe, MD, Yoshinori Imai, MD,
Naoki Ishida, MD, Yusuke Nakagawa, MD, Tomoyuki Nagaoka, MD,
Yusuke Nishi, MD, Uwajima city hospital

Opioid use has become a prevalent issue in our society and therefore many patients who
undergo elective surgery are taking opioids pre-operatively for pain management. To assess
the impact of patients who had pre-operative opioid use vs. those who were opioid naive, a
data analysis was performed from a prospectively collected clinical quality improvement
(CQI) dataset of 109 patients who underwent laparoscopic ventral hernia repair between
6/2012 and 3/2015 (33 months).
There were 28 patients (26%) who were taking opioid medications for pain and 81 patients
(74%) who were opioid nave pre-operatively. In the opioid group, the average age was 58.6
years (3785), BMI was 35.0 (22.957.6) and the number of recurrent hernias was 19/28
(67.9%). For patients who were not taking opioids, the average age was 59.3 years (2193),
BMI was 35.9 (18.062.4) and the number of recurrent hernias was 40/81 (49.4%).
During this time period for this analysis, attempts at process improvement for pain management included the addition of multi-modal peri-operative pain management with
transversus abdominus plane (TAP) and intraoperative blocks using long-acting local
anesthetic to address somatic pain and a low pressure pneumoperitoneum system to address
visceral pain.
For the opioid group, OR time was 135.6 minutes (38294), length of stay was 4.4 days
(017), average PACU morphine equivalent use was 13.0 (043.3) and average total
morphine equivalent use was 242.5 (01714.1). For the non-opioid group, average OR time
was 133.0 minutes (41418), length of stay was 3.4 days (019), average PACU morphine
equivalent use was 8.1 (018.3) and average total morphine equivalent use was 90.2
(0546.6).
In this group of patients who underwent a laparoscopic ventral hernia repair, pre-operative
opioid use was associated with a longer length of stay, and increased PACU and total opioid
use post-operatively.

Broad ligament hernia of the uterus is a rare hernia that may cause small bowel obstruction
through a defect or pouch in a broad ligament of the uterus. Here we report two cases of
broad ligament hernia that were successfully treated by a laparoscopic single-site approach.
A 45-year-old female was admitted due to abdominal pain and vomiting. Abdominal
computed tomography (CT) showed a small bowel obstruction near the broad ligament on
the left side. Intestinal obstruction due to an internal hernia through the left broad ligament
of the uterus was suspected, so we performed an emergency operation. A single incision
was made at the umbilicus, and a defect of the left broad ligament was identified. A viable
ileal loop was incarcerated through the defect. The constricted bowel was easily released,
and the orifice was sutured.
The second case was a 44-year-old female who had abdominal pain, and in whom CT
revealed findings identical to those of the first case. We performed an emergency operation.
There was no bowel necrosis, and the orifice was sutured without resecting the incarcerated
intestine.
We report here two patients in whom we pre-operatively diagnosed small bowel obstruction
due to broad ligament hernia, and who underwent single-site surgery. Both cases had good
postoperative courses.
Broad ligament hernia is rare, and comprises 1.55% of internal hernias. The rate of preoperative diagnosis is low (10.4%), but this has been improved recently by technological
developments in CT. The operative procedure involves releasing incarcerated bowel, and
closing or opening an orifice. A laparoscopic single-site approach uses one trans-abdominal
incision rather than multiple sites for trocar placement. The procedure is designed to
decrease abdominal wall trauma and improve cosmesis. The two cases reported herein
suggest that broad ligament hernia of the uterus should be considered in cases of small
bowel obstruction in female patients, and that single-site laparoscopic surgery is effective if
bowel drainage has been performed.

P317

P319

Total Extraperitoneal Repair for Inguinal Hernia Under

Combined Spinal Epidural Anaesthesia vs General Anaesthesia:
A Randomised Control Trial

Laparoscopic Total Extraperitoneal (TEP) Repair of Inguinal

Hernias Using Manual Dissection Instead of a Balloon Dissector
Potential Cost Savings

Naveen Sharma, Amit K Kundu, Medha Mohta, UCMS Delhi

Simran K Randhawa, MD, Lawrence N Cetrulo, Alisan Fathalizadeh,

MD, Pak S Leung, MD, Danielle Bilsland, BSN, Amit R Joshi, MD,
FACS, Einstein Healthcare Network

Introduction: Totally extraperitoneal repair (TEP) for inguinal hernia is usually performed
under general anaesthesia (GA). Some reports have considered TEP to be feasible under
locoregional anaesthesia.This study compared ease of surgery of performing TEp under GA
versus combined spinal and epidural anaesthesia (CSEA).
Objectives: To compare ease of performing TEP under CSEA with that of performing TEP
under GA.
Methods and Procedures: This was a pilot study since ease of surgery had not been
compared in a randomized controlled trial before. We took a sample size of 20 in each
group.The trial was cleared by the Institutional Ethics Committee and was registred in the
Clinical trials registry of India.The primary outcome measure was ease of performing
surgery measured by NRS.Mann Whitney U test was used to compare the ease of
performing surgery, patients satisfaction, and postoperative pain. Student t test was used
to compare the duration of surgery.
Results:The basechine characteristics of the two groups were comparable.Of the 20 patients
allocated to CSEA group,one was converted to open hernia repair and excluded from
analysis.Of the 19 patients analyzed, 10 had to be converted to GA.
Pain scores and patient satisfaction scores were almost similar between the groups. TEP
under CSEA took an average of 100 minutes compared to 71 minutes for TEP under
GA.The median ease of surgery scores in GA was 10 (IQR 9.2510) compared to 9 (IQR
610) in CSEA group (p=0.002).
Discussion: It was not easy to operate on a patient who was straining, agitated due to pain
in shoulders and chest and at times complaining of breathing difficulties. All these factors
lead to a comparatively more difficult surgery in the CSEA group. No study in the past has
compared ease of performing TEP under the two groups. Though, some previous
researchers found it convenient and even advocated that TEP should be routinely performed
under locoregional anaesthesia. Difficulties were more frequently encountered during sac
dissection and mesh placement.
Conclusion: CSEA is appropriate for performing TEP only in a limited subset of patients
but in most of the cases it is associated with a difficult surgery with prolonged surgery
duration. It should definitely be avoided during the learning curve of a surgeon.

123

Background: Inguinal hernia repair is the most common procedure performed by a general
surgeon. With growing use of laparoscopic inguinal herniorrhaphy, the purpose of this
study is to outline a modified technique using focused (non-balloon) dissection and evaluate
its impact on operative time and post-operative pain.
Methods: We performed a retrospective review of all patients, from 2011 to 2015, who
underwent an ambulatory laparoscopic TEP repair of a unilateral primary inguinal hernia
with mesh by a single surgeon. The conventional surgical technique was modified by
eliminating the employment of a balloon dissector to create the extra-peritoneal space.
Instead, focused manual dissection from the anterior superior iliac spine to the pubis was
performed. We measured operative time and immediate post-operative narcotic
requirement.
Results: A total of 32 patients met the inclusion criteria. All cases were completed
laparoscopically using polyester mesh and absorbable spiral tacks. There were no intra- or
post-operative complications. Mean operative time was 116.63 24.27 minutes (range
35179 minutes). The mean oral and intravenous narcotic use was 16.378.63 mg of oral
oxycodone equivalent/patient. No recurrences were observed in this group.
Conclusion: The technique of focused dissection without a balloon insufflator provides a
cost-effective method of laparoscopic TEP repair that aims towards reducing operative time
and post-operative pain control. It is also a useful technique in resource-depleted settings,
where balloon dissectors may not be available or may be too expensive, consequently
saving the hospital nearly $320 per case. Further randomized control trials will be necessary
to validate the study.

Surg Endosc (2016) 30:S325S500

S407

P320

P322

Progressive Preoperative Pneumoperitoneum Complementing

Chemical Component Relaxation in Complex Ventral Hernia
Repair: Benefits and Complications

Risks of Laparoscopic Versus Robotic-Assisted Mesh Removal

After Inguinal Hernia Repair

Kristen E Elstner, MBBS1, Anita S Jacombs, MBBS, PhD2,

John W Read, FRANZCR3, Michael Edye, FRACS4, Nabeel Ibrahim,
FRACS5, 1Macquarie University Hospital, Sydney, Australia,
2
Faculty of Medicine & Health Sciences, Macquarie University,
Australia, 3Castlereagh Imaging, St Leonards, Australia, 4Professor
of Surgery and Chair, University of Western Sydney, 5Hernia
Insitutue Australia, Edgecliff, Australia
Introduction: Repair of complex ventral hernia, and particularly those with large defects suffering significant loss of domain, is a challenging situation for any surgeon. Closure of large defects is fraught with
possible complications, such as dehiscence, impaired venous return, organ dysfunction, and impaired
ventilation. First described in 1947, Progressive Preoperative Pneumoperitoneum (PPP) is a technique
designed to expand the capacity of the abdominal cavity, thereby facilitating fascial closure at time of
operation and reducing the risk of raised intra-abdominal pressures and its sequelae. We present a series of
patients treated with PPP, along with chemical component relaxation, prior to elective laparoscopic repair of
complex ventral hernia.
Methods: A series of 13 patients with loss of domain greater than 20% underwent short term PPP prior to
elective repair of ventral hernia. A 6Fr peritoneal catheter was inserted into the left upper quadrant (or where
feasible) 710 days preoperatively, with progressive insufflation of air into the peritoneal cavity. Insufflation
was dictated by patient tolerance, averaging 8001000 mls every second day. Patients were monitored
clinically as well as radiologically, with serial non-contrast abdominal CT imaging. Patients then proceeded
to laparoscopic or laparoscopic-assisted repair of their ventral hernia.
Results: Between 2013 and 2015, PPP was performed in 13 patients. Defect size averaged 237 cm2 (range
34459) with loss of domain ranging between 20 to 41%. Mean patient age 55, and mean BMI was 32 kg/m2
(range 22 46). All patients had multiple previous abdominal operations and failed ventral hernia repairs.
Complications included surgical emphysema (n = 2, 15.3%), pneumothorax (n = 3, 23.1%), pneumomediastinum (n = 3, 23.1%), and metabolic acidosis (n= 1, 7.7%). No bowel perforations occurred.
All patients proceeded to successful laparoscopic or laparoscopic-assisted repair of ventral hernia. Fascial
closure was feasible in all patients.
Conclusions: PPP is a rarely utilized adjunct in complex abdominal hernia surgery, despite many successful
anecdotal reports in the literature. The literature states that PPP delivers pneumatic expansion of the
abdominal wall, but in fact may be demonstrating the difference between unstretched versus stretched
abdominal wall (without actual expansion). In our experience, the main advantage of PPP is in postinsufflation imaging, which can identify sites on the abdominal wall which are safe to use as an access point
into the previously operated-on abdomen. Its benefits, however, must be weighed with its pitfalls: risk of
complications such as pneumothorax, pneumomediastinum, and metabolic acidosis.

P321
Laparoscopic Repair of Large Type II and III Hiatal Hernia:
Potential Utility of Crural Reinforcement with a Synthetic
Absorbable Mesh

Erfan Zarrinkho, BA, Shirin Towfigh, MD, Beverly Hills Hernia

Center
Introduction: Laparoscopic mesh removal after inguinal hernia repair with mesh is considered to be
complex and poses risk for very serious complications such as injury to major vessels, peripheral nerves, the
bladder, and the spermatic cord. Robotic-assistance may help decrease the risk of these injuries.
Methods: Retrospective review of all patients who underwent inguinal hernia mesh removal via laparoscopic and robotic assisted techniques.
Results: From September 2011 to 2015, 25 mesh removals were performed either laparoscopically or with
robotic assistance.

Mesh Removal
Laparoscopic

Robotic

17

Age, average

48 years

49 years

NS

Sex, male

65%

62%

NS

BMI, average

28 kg/m2

26 kg/m2

NS

Chronic pain

12 (70%)

7 (78%)

Recurrence

5 (30%)

2 (22%)

Laparoscopic w/mesh

7 (41%)

8 (89%)

Open w/mesh

10 (59%)

1 (11%)

Vascular injury:

Epigastric vessels

Primary reason for mesh removal:

P-value

NS

\0.001

Prior repair history:

\0.001

External iliac vessels

Nerve injury:

Spermatic cord injury:

NS

Bladder injury

NS

Length of Stay (median, range)

0 days (09)

0 days (03)

NS

NS

Conclusions: Both laparoscopic and robotic-assisted techniques for mesh removal are considered advanced
and should be performed by those who are highly skilled in these techniques and very familiar with the
complex anatomy in the pelvis. That said, both techniques should be considered as a viable option for mesh
removal in the retroperitoneal field, to reduce postoperative stay and recovery. The robotic-assisted technique may result in lower risk for serious complications, possibly due to better visualization and more
refined handling of tissues.

Emanuele L.G. Asti, Andrea Lovece, Andrea Sironi, Luigi Bonavina,

IRCCS Policlinico San Donato
Background: Laparoscopic repair of large mixed and paraesophageal hiatal hernia, which represent up to
15% of all hiatal hernias, is associated with high recurrence rate. The use of mesh to reinforce the hiatus can
decrease the recurrence rates but may cause severe complications, such as postoperative dysphagia and
visceral erosion. We designed a case control study to test this hypothesis.
Objectives: The primary end points of the study were safety and efficacy of a synthetic, absorbable mesh for
hiatus repair in the laparoscopic treatment of large (C5cm) type II and III hiatal hernia.
Methods: From October 2009 to September 2014, 80 patients were included in the study. Forty patients
(Group A) underwent crura repair, reinforcement with polyglycolic acid trimethylene carbonate mesh (Bio
A, Gore) and fundoplication; 40 patients (Group B) underwent simple crura repair and fundoplication. We
investigated pre and postoperative symptoms using the GERD-HRQL questionnaire. Barium swallow study
and upper endoscopy were performed at 6 months post-operatively and then yearly to detect recurrences and
mesh related complications.
Results: All the operations were completed laparoscopically. After a mean follow-up of 36 months (IQ
range: 1854), no mesh-related complications occurred. The incidence of persistent grade II dysphagia was
3% in each group (p=NS). Reflux symptoms requiring anti-secretory drugs accounted for 5% of patients in
group A, and 12,5% for group B (p=0,1). Recurrent hiatal hernia (C 2cm) was detected in 3 patients (10%)
in the group A and in 8 patients (27%) in the group B (p=0,080). Only 3 patients in group B were
symptomatic.
Conclusions: Laparoscopic repair of large hiatal hernia using an absorbable synthetic mesh is safe and
effective and may reduce the anatomical recurrence rate.

P323
Preliminary assessment of Laparoscopic Transabdominal PrePeritoneal (TAPP) Repair of Recurrent Inguinal Hernia: Review
of 10 Consecutive Cases
Manabu Amiki, Masato Yamazaki, Ryota Sakon, Takahiro Inoue,
Shun Sato, Mikihisa Nakayama, Masataka Oneyama, Kazuhiro
Narita, Ryo Ota, Manabu Goto, Kawasaki Saiwai Hospital
Purpose: We conducted an initial assessment of the efficacy of laparoscopic transabdominal pre-peritoneal
(TAPP) repair performed at our hospital in cases of recurrent inguinal hernia.
Methods: We reviewed the cases of 11 patients treated for recurrence of inguinal hernia at our hospital and
Saiseikai Kurihashi Hospital between 2012 and 2015, The 11 cases were consecutive and involved 12
hernias (unilateral, n=10; bilateral, n=1). The recurrence was treated by laparoscopic transabdominal preperitoneal (TAPP) repair in all 11 patients. We first noted patients age and sex and then examined whether
the recurrence was related to the type of hernia (direct or indirect). We then looked at outcomes of the TAPP
repair in relation to the type of initial surgical repair (conventional or Lichtenstein or Meshplug), time to
recurrence, and type of recurrence (direct or indirect), and we investigated whether any complications arose
from the TAPP repair, In addition, we looked at TAPP repair time and post-operative hospital stay and
compared them with initial repair time and initial post-operative hospital stay.
Results: All patients were men, and they ranged in age at the time of TAPP repair from 53 to 83 years
(mean, 75 years). The initial inguinal hernia repairs were performed by the conventional method (n=3) or the
Lichtenstein (mesh) method (n=8) or the Meshplug method(n=1). The time to recurrence was about 50 years
in the case of conventional repair and 1 to 4 years in the cases of Lichtenstein and Meshplug repair. The
recurrences were of the direct type (n=3) or the indirect type (n=9), and they were unrelated to the original
hernia types. Median TAPP repair time was 88 minutes (79 to126 minutes) and slightly longer than the
initial operation time of 71 minutes (47 to 309 minutes). The same TAPP procedure was used for 12 of the
recurrent hernias. In all cases, post-operative hospital stay after the TAPP repair was 3 days, like that
following the initial hernia repair. There were no post-TAPP repair complications, and there has been no
relapse during the relatively short follow-up period of 15 to 24 months.
Conclusion: TAPP repair appears to be to be a reliable surgical option for recurrent inguinal hernia.

123

S408

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P324

P326

Efficacy of the Anterior Rectus Sheath Hinge Graft for Umbilical

Hernia Repair Reinforcement

Feasibility and Safety of Single Incision Totally Extraperitoneal

Inguinal Hernia Repair After Previous Open Inguinal Hernia
Repair: A Case-Mached Analysis

Francis B Baccay, MD1, Melanie Howell, MD1, Irene J Lo, MD2,

Jai P Singh, MD3, 1Montefiore Medical Center/Albert Einstein
College of Medicine, 2West Coast Surgical Associates, Inc, 3SUNY
Upstate Medical Center
Introduction: The anterior rectus sheath has been used in various hernia repairs to traverse
the defect. In this series, we describe a novel technique that uses the anterior rectus sheath
as a reinforcement material for the open umbilical hernia repair. We report our experience
with this innovative approach.
Method: A total of 54 consecutive umbilical hernia patients including 34 (63%) elective
and 20 (37%) emergent were repaired. All hernias were repaired using open technique
employing an omega incision centered around the umbilicus. The umbilical hernia was
primarily repaired in transverse fashion. The repair was reinforced with medial mobilization
of an anterior rectus sheath hinge flap that was sutured directly to the hernia repair suture
line. No synthetic or biologic reinforcement material used.
Result: There were no recurrences or re-admissions. Mean age was 52.2 years (2778
years), mean body mass index of 36.3 kg/m2 (25.342.2kg/m2), mean follow-up was 36.2
months (1054 mo), and mean length of stay was 3.8 days (06 days). There were 16
patients (29.6%) with ascites with mean MELD score 12.4 (820). There were 2 (3.7%)
wound infections. There were 6 patients (11.1%) that required bowel resection.
Conclusion: We describe a novel technique to open umbilical hernia repairs obviating the
need for any prosthetic material. The direct suture line reinforcement of the anterior rectus
sheath flap maintained proper flap alignment and reduced tension at the suture line. Larger
prospective trials comparing outcome with standard techniques are warranted.

Masaki Wakasugi, Mitsuyoshi Tei, Toru Masuzawa, Kenta Furukawa,

Yozo Suzuki, Kentaro Kishi, Masahiro Tanemura, Hiroki Akamatsu,
Osaka Police Hospital
Purpose: To evaluate the feasibility and safety of single incision laparoscopic surgery for
totally extraperitoneal repair (SILS-TEP) after previous open inguinal hernia repair.
Methods: A matched pair analysis of 260 patients who underwent SILS-TEP for unilateral
inguinal hernia from January 2011 to June 2015 at Osaka Police Hospital was performed.
The recurrent hernia group consisted of 15 patients (6%, 15/260) with a history of previous
open inguinal hernia repair before undergoing SILS-TEP. Patients in the control group were
matched in terms of age, gender, side of hernia, body mass index, American Society of
Anesthesiologists scores with the same number of patients from the 245 primary inguinal
hernia patients.
Results: The mean operative time in the recurrent and the control groups was 89 min and
93 min, respectively (p = 0.6). The mean postoperative hospital stay was 2.9 days for the
recurrent group and 2.1 days for the control group (p = 0.2). Two cases in the recurrent
group were converted to one conventional three-port TEP repair and one open repair. One
case in the control group was converted to conventional three-port TEP repair. There was
no significant difference in conversion to a different procedure between the two groups (p =
1). Complications were seen in 33% (5/15; 4 seromas and 1 wound infection) of patients in
the recurrent group and 7% (1/15; 1 seroma) in the control group (p = 0.1). No other major
complications and hernia recurrence were noted in the two groups.
Conclusions: SILS-TEP for patients with previous open inguinal hernia repair could be
performed safely by experienced surgeons. Operative outcomes were comparable between
both the primary inguinal and recurrent hernia groups.

P325
P327
Comparison of the Perioperative QOL in Inguinal Hernia
Surgery -Between Laparoscopic and Open SurgeryMasahiro Ishizaki, MD, R Sugimoto, MD, N Iga, MD, R Yoshida,
MD, H Ikeda, MD, N Waki, MD, H Kawai, MD, H Nishi, MD,
K Yamashita, MD, Okayama Rosai Hospital
Introduction: Laparoscopic repairs are getting mainstream in inguinal hernia surgery.
There are some opinions that the early and chronic QOL are better in laparoscopic surgery
than open surgery, but those have not been evaluated properly. So we made questionnaires
about QOL after surgery and compared the VAS scores between laparoscopic and open
surgery.
Methods and Procedures: 110 patients (101 males and 9 females) had inguinal hernia
repairs in our hospital from December 2013 to September 2015. Sixty six patients had
laparoscopic surgery (13 both sides) and 44 had open surgery (2 both sides). All laparoscopic surgeries were TAPP procedures. Open operations contain 33 transinguinal
preperitoneal repairs (polysoft), and 11 mesh plug repairs. Medical secretaries gave questionnaires to those patients at 13 days after surgery, and at 23 weeks after surgery (at first
outpatient visit). VAS (Visual analog scale) scores were collected by medical secretary.
Questions are about Disturbance with walking, Sensing of bloating, Pain, Sensing of foreign
body, and Swelling of wound. We used T-Test to evaluate the VAS scales.
Results: Mean operative time was 145.4 and 69.5 minutes in laparoscopic group and open
group respectively. The mean admission periods after surgery was 4.2 and 3.1 days. P
values of T-test of VAS scores concerning Disturbance with walking, Sensing of bloating,
Pain, Sensing of foreign body, and Swelling of wound in 3 days were 0.01, 0.002, 0.01, 0.75
and 0.59 respectively, in favor of open group. But P values of VAS scores in 3 weeks were
0.92, 0.66, 0.49, 0.09 and 0.24 respectively, without any differences between those two
groups. Some researchers reported that laparoscopic hernia repair induces less pain than
open hernia repair. In ours series of 110 patients early QOL with Disturbance with walking,
Sensing of bloating, Pain was statistically better in open group. Perioperative QOL of open
inguinal hernia surgery was not inferior to laparoscopic surgery.
Conclusion(S): Open inguinal hernia surgery should be reevaluated to be chose in day
surgery. We need to experience more cases and explore the early and long term QOL of
both procedures to find out the best operations for inguinal hernia.

123

A Comparative Study to Assess the Efficacy of Absorbable Versus

Permanent Fixation Tacks in Laparoscopic Ventral Hernia
Repair
Eva Lourdes, Sujith Wijerathne, Siau Wei Tang, Davide Lomanto,
Prof, Minimally Invasive Surgery Centre, Department of Surgery,
National University Health System, Singapore
Introduction: Laparoscopic repair of ventral hernia is increasingly becoming the standard
of care in many institutions. However, debates still exist regarding the approach, the role of
mesh fixation and the type of fixation device used. Our study aims to compare the outcomes
of patients who underwent laparoscopic ventral hernia repair with an absorbable fixation
tack to those who had a permanent (non-absorbable) fixation tack.
Methods: This is a treatment based, retrospective study involving patients who underwent
laparoscopic ventral hernia repair at a single institution. Patients were divided into two
groups based on the type of fixation tack used (absorbable or permanent), irrespective of the
mesh used. Post surgery, patients were routinely followed up in the outpatient clinic and
their notes were reviewed to record demographic data, surgical details, complications, level
of pain and the recurrence of ventral hernias.
Results: All patients underwent laparoscopic repair of ventral hernia during the period
20112014. We compared 57 patients who had absorbable fixation tacks (Group A) to 37
patients who had permanent fixation tacks (Group B). Most patients presented with cosmetic concerns (86% in A vs 92% in B) or pain (12% in A vs 8% in B). Post-operatively,
81% of patients from Group A and 73% of patients from Group B developed acute pain,
defined as pain requiring more than 1 type of analgesia. Seromas were found in 2% of
patients in Group A and 11% in Group B (p=0.011). Recurrence rates of ventral hernia were
3% in both Groups A and B.
Conclusion: The overall incidence of complications for both types of tacks is low and both
fared equally well in providing mesh anchorage as evidenced by a low recurrence rate of
hernia. With regards to pain, no significant difference was demonstrated in our study, as
assessed by the use of analgesia, a surrogate measure of pain. Absorbable and permanent
fixation tacks may be used in laparoscopic ventral hernia repair with equal effect.

Surg Endosc (2016) 30:S325S500

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P328

P330

Predicting Risk Factors Likely to Cause Early Recurrence

Following Laparoscopic Ventral/Incisional Hernia Repair

Short-Term Outcomes Post Laparoscopic Abdominal Wall

Reconstruction: A Novel Approach and Prospective MultiInstitutional Case Series Study

Nehemiah Samuel, Mr, Fayyaz A Mazari,

Mr, Muhammad H Shiwani, Mr, Barnsley Hospital NHS Foundation
Trust
Aim: To assess our experience in laparoscopic repair of ventral and incisional hernias(LRVIH) and
predict risk factors likely to cause recurrence over early follow-up period.
Methods: Prospective single centre study of consecutive LRVIH performed by one Consultant
Surgeon over last 4 years. Patient demographics, periprocedural details, recurrence at follow-up
were all recorded. Hernias were classified according to Europen Hernia Society (EHS) classification. Univariate and Multivariate analysis were performed to associate risk factors with hernia
recurrence.
Results: 90 patients M:F 42:48; mean (SD) age 56.5(13.9) years; BMI of 32 (6.1) kg/m2; Smokers
22 (24.4%); ASA: 2 (60%), 3 (13.3%), 4 (1.1%) underwent repairs for 19 (21.1%) primary ventral
hernias, 61 (67.8%) incisional hernias and 10 (11.1%) recurrent-incisional hernias. The median
(i.q.r.) defect size was 25 (12108) cm2; with EHS classified width: W1=26.7%, W2=45%,
W3=24.4%; 16 patients had complications: 8 (8.8%) seromas, 1 (1.1%) haematoma, 4 (4.4%)
respiratory complications; 3 (3.3%) conversions to open and 1 (1.1%) re-operation for small bowel
obstruction. There were 5 (5.5%) recurrences over 1-year follow-up period. There were no significant predictors of recurrence on univariate logistic regression for risk factors of Gender, Age,
BMI, Smoking status, ASA, Type of hernia, Width and Type of Mesh. However controlling for the
above factors, multivariate regression demonstrated the width of the defect as a significant predictor for recurrence OR (95%CI) 6.20 (1.1234.33) P=0.037
Conclusions: LRVIH is safe and effective with low early recurrence rates. It can be offered to the
elderly, obese patients, and those with significant comorbidities without increased risk of early
recurrence. Wider defects carry a higher risk of recurrence with LRVIH, however the risk is
comparable to recurrence with open repairs and carries the significant advantage of low morbidity
and early recovery.

P329
Clinical and Quality of Life Assessment of Patients Undergoing
Laparoscopic Hiatal Hernia Repair

Hamid R Zahiri, DO1, Olmos I Holmatova, MD1, Heidi Miller, MD2,

Adrian E Park, MD, FACS1, Yuri W Novitsky, MD, FACS2, Igor
Belyansky, MD, FACS1, 1Anne Arundel Medical Center, 2University
Hospital Case Medical Center
Background: Rives and Stoppa technique involves placement of mesh between the rectus muscle
and the posterior rectus fascia, often referred to as a retrorectus repair. As direct evolution of this
surgical approach, Transversus Abdominis Release has been one of the recently described surgical
approaches that adds to a growing armamentarium of AWR techniques and has been widely
embraced by hernia surgeons. We present a series of patients that underwent a novel minimally
invasive TAR and Rives Stoppa approaches to address complex hernia defects, completed entirely
laparoscopically at two hernia centers.
Methods: Eleven patients underwent laparoscopic AWR for complex hernias in August and
September of 2015 at two institutions: Anne Arundel Medical Center and University Hospital Case
Medical Center. Operative approach consisted of lysis of adhesions (as necessary), bilateral posterior rectus sheath release, closure of the posterior fascial layer, closure of the anterior abdominal
wall defect and large mesh implantation. When appropriate bilateral transversus abdominis release
was performed to achieve anterior defect closure.
Short-term (30-day) outcomes were analyzed, including wound and non-wound related complications, as well as, preoperative and postoperative quality of life (QOL) using Carolinas Comfort
Scale (CCS).
Results: Six males and Five females with mean age and BMI of 64.2 and 30.7, respectively,
underwent a mean OR time of 354.7 minutes. There were 6 TAR and 5 Rives Stoppa procedures.
Average mesh area used was 837.5 cm2. Mean EBL and LOS were 100.0 cc and 5.7 days,
respectively. No subcutaneous flaps were raised avoiding the need for subcutaneous drains. There
were no perioperative complications. All of the subfascial drains were removed prior to patient
discharge. On initial follow-up visit at four weeks, there was no evidence of wound complications,
bulging or hernia recurrences.
QOL assessment with CCS in the first 30 days showed 50% of patients had improvements in pain
and mobility after surgery compared to their baseline (prior to surgery). One patient had increased
pain, although, this was not significant (C2 on scale)
Conclusion: Laparoscopic TAR and Rives Stoppa repairs are novel surgical approaches to complex abdominal wall defects. These interventions have the potential to reduce early perioperative
pain, facilitate recovery and decrease length of hospital stay for patients. Their place in the field of
AWR is yet to be determined. Further work will focus on patient selection as well as reporting
long-term outcomes.

P331
Closure of Defect During Laparoscopic Incisional Hernia Repair:
Long Term Follow-Up Results

Daniel Borman, Kyle Sunshein, Daniel Davenport, Margaret Plymale,

John S Roth, University of Kentucky

Deborshi Sharma, Prof, Dr, Lady Hardinge and Dr RML Hospital

Introduction: The role of reinforcing mesh in the repair of hiatal hernias is often debated. Synthetic mesh has been demonstrated to reduce recurrences, although mesh erosions have been
reported and can be catastrophic. Prospective randomized trials utilizing biologic mesh materials
have demonstrated a reduction in short-term recurrences. Polyglycolic acid/Trimethycellulose
(PGA/TMC) mesh is an absorbable synthetic that may be utilized to reinforce the hiatal closure
during repair. This study evaluates quality of life (QOL) and clinical outcomes of patients
undergoing laparoscopic hiatal hernia repair (HHR) with PGA/TMC mesh.
Methods: A retrospective review of a single surgeons cases of HHR utilizing PGA/TMC mesh
between August 2012 and April 2014 was performed. Patients were identified from an institutional
surgical database and demographics, preoperative studies, intraoperative details and postoperative
outcomes were recorded. For symptom evaluation, patients completed a gastroesophageal reflux
disease quality of life (GERD QOL) questionnaire during each office visit. Questionnaire responses
were evaluated according to 3 time periods: preoperative, postoperative within 6 weeks and
postoperative between 6 weeks and 6 months. For patients that returned demonstrating postoperative symptoms, additional evaluation occurred and was noted.
Results: 97 patients underwent HHR with PGA/TMC mesh and either Nissen (n= 69) or Toupet
(n= 27) fundoplication. Average age was 58.2 years (SD = 14.8); 66% of the patients were female.
Average BMI was 30.3 (SD = 6.2). Hernia defect size was classified as large ([ 5cm, n= 49),
moderate (35cm, n= 32) or small (\3cm, n= 12). Mean hernia defect size increased in proportion
to the mean age of the patient (Large 65y, moderate 53y, small 46 y, ANOVA p\.001). Operative
time was noted to be higher in patients with a large defect (Large 169 min., moderate 142 min.,
small 145 min., ANOVA p=.004) A total of 224 GERD QOL questionnaires were recorded and
analyzed. Postoperatively, the number of patients reporting heartburn, solid dysphagia, liquid
dysphagia, vomiting, regurgitation, hoarseness and chronic cough significantly decreased (p\.05).
While post-operatively patients initially reported decreased bloating, this number returned to
baseline by the second follow up period. During the entire study period, 6 patients were noted to
have radiographic hernia recurrence with 2 of these patients requiring reoperation.
Conclusions: Patients undergoing HHR with PGA/TMC mesh experience positive clinical and
quality of life outcomes, as indicated by patient-reported surveys and postoperative radiographic
findings. In addition, our patients experienced decreased rates of dysphagia and minimal radiographic recurrence.

Introduction: Ventral hernia repair has local complications and high recurrence rates. Laparoscopic ventral hernia repair (LVHR) has reduced some complications however left many
unanswered. Consensus is building towards closure of defect during LVHR, creating better
abdominal wall dynamics and reducing local complications. We analyze and present our 7 year
results of LVHR with defect closure (IPOM plus)
Materials & Methods: All LVHR done between July 2007 and June 2014 with a minimum followup of 1year included. Defect closure was done by intracorporeal suturing using a non absorbable
monofilament suture. Data was prospectively collected and patients were followed up for maximum
7 years from hospital records, unit follow up data and telephone calls made for uncertain records.
Post-operative complications were analyzed and compared between Group I: Defect complete
closure, Group II: Defect incomplete closure and Group III: Defect not closed. Analysis was done
using SPSS 17. Data was analyzed using Chi Square/Fischer Exact test. P-value of \0.05 taken as
significant.
Results: After excluding recurrent hernia and lateral hernias, 181 ventral midline hernias were
operated (Primary Hernia N=96, Incisional Hernia N=85). Vertical hernia size in 83 patients were
B5cm, 76 had 510cm, and 22 between 1020cm. Mean follow-up was 51months (Range 17yrs).
Defect closure was attempted in 86/181 (47.51%) - 36, 35 and 15 patients with Hernia sizes B5cm,
5.110cm and 10.120cm respectively. All patients with defect size B5cm (36/36) had complete
defect closure while 20 with defect sizes 5.110cm (5/35) and 10.120cm (15/15) had incomplete
closure of defect. Closure attempted Group I&II had longer operating time than Group III (114min
vs 95min) (P-Value 0.104).
Hernia size B5cm, Group I had no incidence of Post operative buldge(POB), Seroma or recurrence
while group III had POB in 2.1% and Seroma in 21.2%.
Hernia Sizes 5.110cm, Seroma was seen in 13.3% in Group I, while it was 60% and 24% in Group
II and III respectively (P-value 0.021). Three recurrences (7.3%) were seen in Group III within 1
year.
Hernia Size 10.120cm, Seroma was seen in 4(57.1%), POB in 6(85.7%) and recurrence in
2(28.5%) in Group III. Complications were highest in Group II&III, particularly when hernia size
was 10.120cm (P-value 0.043).
Conclusion: Defect closure gives significantly better patient outcome and result among all hernia
sizes. However all defects beyond C5cm may not be amenable for defect closure. Partial/Incomplete closure even has better results than non closure of defect except in terms of seroma formation.

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P332

P334

A Retrospective Study to Assess the Efficacy of Condensed

Polytetrafluoroethylene Mesh in Laparoscopic Ventral Hernia
Repair

Reductions in Midline Fascial Closure Force After Laparoscopic

and Open Transversus Abdominis Release in a Porcine Model

Eva Lourdes, Siau Wei Tang, Jesse Hu, Wee Boon Tan,
Davide Lomanto, Prof, Minimally Invasive Surgery Centre,
Department of Surgery, National University Health System,
Singapore
Introduction: Laparoscopic ventral hernia mesh repairs are increasingly performed as it has been associated with less postoperative pain, decreased wound morbidities, shorter hospital stay and faster return to activity. Traditionally, this is performed using
a dual layer composite mesh which has an absorbable collagen barrier on the visceral surface to allow tissue ingrowth yet
minimising bowel adhesions. The 3 most common prosthetic mesh scaffolds are polypropylene (PP), polyester, and expanded
polytetrafluoroethylene (ePTFE). The Omyra mesh is a monolayer condensed polytetrafluoroethylene (cPTFE) mesh which allows
for better tissue integration with the parietal tissue, yet have reduced adhesions with the visceral organs. The aim of this study is to
assess the safety and efficacy of Omyra mesh in laparoscopic ventral hernia repair in a single institution.
Method: From January 1, 2011 to March 31, 2015, we retrospectively collected data from patients who underwent laparoscopic
ventral hernia repair using the Omyra mesh. Patient demography, type of hernia, operative details and postoperative recovery and
complications were collected and analysed.
Results: There were 26 patients who had laparoscopic ventral hernia repair with the Omyra mesh with a mean age of 58 (range:
3185 years) and mean BMI of 27.95 (range: 18.637.3). Of these 26 patients, 17 were female and 9 were male. Patients were
symptomatic with a mean range of 24 months (range: 3 days 48 months). Characteristics of the ventral hernia included 9 primary
hernias and 17 incisional hernias. Of the 17 incisional hernias, 10 were midline hernias 7 were lateral. The mean size of the defect
was 8.5 cm (range: 215cm), with mean operative time of 146 mins (range: 43249 mins). Twenty patients had an incarcerated
hernia containing omentum and/ or small intestine. There was no early postoperative mortality. The mean length of stay was 6 days
(range: 110). Early postoperative complications (\30 days) were seroma (n=4), superficial wound infection (n=2) and ileus (n=2)
which were treated conservatively. Late complications ([30 days) were superficial wound infection (n=1) and 2 patient developed
recurrence. The recurrence occurred at 6 and 16 months after the procedure. Mean follow up 35 weeks (range: 168 weeks).
Conclusion: Laparoscopic ventral hernia mesh repair is feasible and safe with an Omyra mesh. Early complications included
seroma, superficial wound infection and ileus with 2 patients having a recurrence at 6 and 16 months.

Joshua S Winder, MD1, Jerome R Lyn-Sue, MD1,

Allen R Kunselman2, Eric M Pauli, MD1, 1Department of Surgery,
The Pennsylvania State University, College of Medicine, Hershey, PA,
2
Department of Public Health Sciences, The Pennsylvania State
University, College of Medicine, Hershey, PA
Introduction: Traditional methods of herniorraphy have unacceptably high recurrence rates. Posterior component separation
herniorraphy via transversus abdominis release (TAR) has a recurrence rate of only 4.7 % at 26 months follow up. To date, no data
has been reported delineating the reduction in tensile force required to reapproximate midline fascia after TAR. Furthermore, a
laparoscopic approach at TAR could provide a minimally invasive and less morbid herniorrhaphy. We hypothesized that open TAR
reduces midline tensile forces, that laparoscopic TAR is feasible, and that laparoscopic TAR provides similar reductions in midline
tension to open TAR.
Methods: In an anesthetized porcine model, a 20 cm midline incision was made and bilateral lipocutaneous flaps were raised to
expose the anterior rectus fascia. Five stainless-steel hooks were placed in the fascia at 1 cm intervals lateral to the midline 5 cm
above, at, and 5 cm below the umbilicus (Fig. 1). Baseline force measurements were taken by pulling each point to the midline. A
temporary laparotomy closure was applied. Laparoscopic TAR was performed unilaterally by incising the parietal peritoneum
10 cm lateral to the midline and dividing the transversus muscle along its entire length. Subsequently, open TAR was performed on
the contralateral side. Repeat force measurements were then taken. Comparisons were made before and after TAR and between the
open and laparoscopic groups.
Results: Laparoscopically, 87 % (13/15) of points showed statistically significant reduction in force after TAR than before. For
open releases only 3/15 (1 cm lateral to the umbilicus, and 1 and 2 cm lateral to midline below the umbilicus) had significant
reduction in force following TAR. When comparing laparoscopic vs. open TAR, three locations were statistically significant in favor
of laparoscopic TAR (1 cm lateral to midline above the umbilicus (p = 0.04; 95 % CI 0.781.00), 2 cm lateral to midline at the
umbilicus (p = 0.04; 95 % CI 0.801.00), and 1 cm lateral to midline below the umbilicus (p = 0.05; 95 % CI 0.791.00)]. The
mean length of TAR was significantly longer for laparoscopic than open at 27.29 cm and 19.55 cm, respectively (p = \0.0001).
Conclusions: Laparoscopic TAR provides superior reduction in midline closure force compared to open TAR, likely as a result of a
longer and more complete muscle release capable through the laparoscopic approach used in this model. Interestingly, open TAR
reduced midline tensile force in only 20 % of the locations tested, suggesting that the mechanism by which open TAR facilitates
herniorraphy may not be entirely through simply reducing tension on the reconstructed linea alba.

P333
Sleeve Gastrectomy with Hiatal Hernia Repair for Relief
of Gastroesophageal Reflux Disease: Long-Term Outcomes
Craig G Chang, MD1, Lisa Thackeray, MS2, 1Advanced Bariatric
Surgical Specialists, 2NAMSA
Objective: To examine the long-term efficacy outcomes for sleeve gastrectomy (SG) with hiatal hernia repair (HHR) reinforced
with a biologic mesh [VERITAS Collagen Matrix, Baxter Healthcare, Deefield, IL] for long-term relief of gastroesophageal reflux
disease (GERD) symptoms.
Description/Method of Application: GERD after SG is a troublesome problem occurring in 2249 % of patients. SG may produce
de novo reflux or aggravate existing GERD. HHR at the time of SG has been shown to reduce the incidence of postoperative GERD.
Therefore, in our practice, weve taken a very aggressive approach at HHR at the time of the SG as recommended by the
International Sleeve Gastrectomy Expert Panel Consensus Statement. Our specific technique includes reinforcement of the hiatal
hernia with biologic mesh as an onlay following a posterior and anterior cruroplasty.
Short-term efficacy of SG with reinforced HHR to relieve GERD symptoms has been documented. However, long-term efficacy is
questionable, and the few studies performed have focused on larger, paraesophageal hernias. Our study was designed to capture data
as to the efficacy of the combined procedure to reduce and/or alleviate GERD symptoms at long-term follow-up ([2 years) for
smaller (\5 cm, type I and III) hiatal hernias. The primary efficacy outcome measure was relief from GERD symptoms as measured
using a validated survey instrument, the GERDHealth-Related Quality-of-Life Scale (GERD-HRQL)(scale of 0: no symptoms to
50: debilitating symptoms)
Preliminary Results: From July, 2009 to September, 2013, a total of 55 patients underwent SG with HHR. The average hernia size
was 2.3 1.5 cm. The majority of patients presented with a type I hernia (96.2 %). The study included 51 females (92.7 %) and 4
males (7.3 %). All of the patients were obese or morbidly obese with an average BMI of 40.6 7.1. Approximately 90.9 % (50/55)
of the hiatal hernias were diagnosed intraoperatively, while 9.1 % (5/55) were diagnosed preoperatively. The average age was
48.9 11.3 years.
At baseline (preoperative), the mean GERD-HRQL score was 13.0 12.6. At long-term follow-up (median of 34 months), the
score showed a statistically significant decline to a mean of 3.1 5.9 (p \ 0.0001). There were no major complications. Minor
complications included nausea, vomiting and fever that resolved over time.
Conclusions: Sleeve gastrectomy with hiatal hernia repair reinforced with biologic mesh provides long-term relief for existing
GERD symptoms and prevention of de novo GERD symptoms.

Fig. 1 .

P335
A New Strategy for Laparoscopic Repair of Inguinal Hernia
Developed After Robot-Assisted Laparoscopic Radical
Prostatectomy
Toshihiro Ogawa, MD, Hitoshi Idani, MD, FACS, Soichiro Miyake,
MD, Hisanobu Miyoshi, MD, Hiroyuki Araki, MD, Kazutaka
Takahashi, MD, Toshihiko Fujita, MD, Naoki Mimura, MD, Yasuhiro
Komatsu, MD, Kenji Yamaguchi, MD, Hiroaki Inoue, MD, Hiroshi
Ota, MD, Yasuo Nagai, MD, Hijiri Matsumoto, MD, Michihiro
Ishida, MD, Daisuke Sato, MD, Noriaki Tokumoto, MD, Yasuhiro
Choda, MD, Takashi Kanazawa, MD, Masao Harano, MD, Yasutomo
Ojima, MD, Hiroyoshi Matsukawa, MD, Shigehiro Shiozaki, MD,
Masazumi Okajima, MD, FACS, Motoki Ninomiya, MD, Department
of Surgery Hiroshima City Hospital
Background: Surgical procedures for inguinal hernia developed after robot- assisted laparoscopic radical prostatectomy (RALP)
have not yet been established. We have introduced a new strategy for laparoscopic repair of inguinal hernia after RALP and
evaluated the outcome.
Surgical Technique: Under general anesthesia, 3 trocars was inserted at the same position as transabdominal preperitoneal
approach (TAPP). Bilateral inguinal legion was observed carefully and bilateral hernia repair was performed when the hernia was
detected at the contralateral side. At first, preperitoneal space was dissected laterally and then medially enough to detect the Cooper
ligament and pubic bone. After the preperitoneal space was fully dissected, 14 9 10 cm mesh was inserted and fixed with
absorbable tacks. When the Coopers ligament was detected but the medial preperitoneal space could not be further dissected due to
scar formation caused by dissection during RALP, parietex composition mesh was fixed to the Coopers ligament and medial and
cephalad side was directly fixed to the abdomen and the caudal side was sutured and covered with peritoneum (partial intraperitoneal
onlay mesh: PIPOM). When the Coopers ligament could not be detected at all, hernia was repaired by anterior approach.
Methods: From April 2014 to August 2015, seven patients with inguinal hernia developed after RALP underwent laparoscopic
repair in our hospital and its outcome was evaluated.
Results: Mean age of patients was 70.4 years old. There were 4 right indirect hernias, 1 left indirect hernia and 2 bilateral indirect
hernias (one of which was combined with left direct hernia). Two bilateral hernias were diagnosed by laparoscopy. TAPP, PIPOM
and anterior approach were performed on 3, 3 and 1 patients, respectively. Operation time was 142 min for TAPP, 150 min for
PIPOM (including 2 bilateral repair) and 144 min for anterior approach.

Postoperative pain was minimum and well controlled by NSAIDS, which disappeared within a week. Hospital stay
was 3.5 days. Seroma was occurred in two patients which treated conservatively. During the follow-up period of
8 months, there has been no recurrence.
Conclusion: Our new strategy including TAPP and PIPOM is safe and effective although further examination in a large number of
patients and long term follow up will be needed.

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P338

Is the Recurrence Rate of Incisional Hernia Influenced

by Surgical Approach? A Comparative Study with Long-Term
Follow-Up

Simultaneous TEP (Totally Extraperitoneal Approach)

for Inguinal Hernia and Cholecystectomy: A Feasible and Safe
Procedure

Ezequiel Sadava, Martin Galvarini, Romina Reino, Belen Castro

Fuentes, Jose Alvarez Gallesio, Francisco Schlottmann, Hospital
Aleman of Buenos Aires

Norimasa Koide, Takao Kuno, Takahiro Mizukawa, Kenji Kato,

Inazawa Municipal Hospital

Introduction: Laparoscopic approach prevents major abdominal wall incisions and

improves patient recovery. Although laparoscopic incisional hernia repair has proven to be
at least as safe as open repair, the mini-invasive approach has not been standardized.
Several investigations have been conducted about the best method to repair an incisional
hernia, but few reports assess which technique offers better results in terms of durability.
We aimed to evaluate the mid- and long-term results of laparoscopic incisional hernia
repair.
Methods and procedures: From June 2012 to February 2015 all charts of consecutive
patients underwent to incisional ventral hernia repairs were revised. Patients who underwent ventral hernia repair with defects between 15 and 150 cm2 and had at least a minimum
of 6 months of-follow-up were included. Demographics, operative features and post-operative complications were analyzed comparing laparoscopic repair (LR) and open repair
(OR). Also mid- and long-term follow-up was evaluated with focus in hernia recurrence.
Results: A total of 137 patients were included in the study: 34 (25 %) laparoscopic and 103
(75 %) open incisional hernia repairs with synthetic prosthesis. There was no difference in
gender, age, BMI and ASA score between groups (p = NS). The mean defect size was
49 cm2 in LR and 55 cm2 in OR (p = NS). In laparoscopic repairs a composite with antiadhesive barrier mesh was placed in all cases, and heavy-weight polypropylene (78 %) and
composite low-weight macroporous mesh (28 %) were implanted in a sub-lay fashion for
open repairs. There was no difference in operative time (LR: 100 minutes vs OR: 120
minutes, p = NS). There was a significant higher rate of postoperative complications in OR
(LR: 14 % vs OR 41 %, p = 0.007). Length of stay was similar between the two groups
(LR 0.9 days vs G2 1.7 days, p = NS). With a mean follow up of 18 (630) months, the
incidence of recurrence was 10 % in LR and 13 % in OR (p = NS).
Conclusions: Laparoscopic incisional hernia repair showed a reduction in postoperative
complications and hospital stay compared with open approach. At mid- and long-term
follow-up, no difference was found in terms of recurrence.

Introduction: Laparoscopic inguinal hernia repair and cholecystectomy are the most
common surgical procedures in the world. Simultaneous performing both procedures are
rare conditions. This study shows the safety and the possibility of performing a simultaneous TEP and cholecystectomy thought the different extraperioneal and intraperitoneal
approach.
Methods and Procedures: Three male patients with inguinal hernia and cholelithiasis were
included in this study. Mean age of the patients was 68.7 years (ranging from 6575).
Simultaneous laparoscopic cholecystectomy and TEP (seven wounds and 4 trocars) was
performed in all patients. The PDB balloon, hernia staple and clip were not used in this
procedure. Intra and postoperative complications were analyzed to assess the safety and
feasibility of the procedure.
Result: Mean operating time was 392 min (ranging from 364441), mean blood loss was
7.0 ml (ranging from 410) and average length of postoperative day was 4.3 days (ranging
from 45). Two peritoneal tears were occurred during TEP procedure and repaired by hand
sowing. No postoperative complications were observed.
Conclusions: Simultaneous TEP and cholecystectomy was a safe and feasible procedure
except for longer operative time and intraoperative peritoneal tear. However this procedure
may be more cost effective and less postoperative complications.

P337

P339

A Cost-Comparison of Mesh Usage in Laparoscopic

Paraesophageal Hernia Repair

Mesh Prosthetic Soaked in Local Anesthetic for Laparoscopic

Ventral Hernia Repair: A Retrospective Review On PostOperative Pain Control

Amareshewar Chiruvella, MD, Daniel Lomelin, MPH,

Dmitry Oleynikov, MD, University of Nebraska Medical Center
Introduction: Use of absorbable mesh in paraesophageal hernia (PEH) repair has been
shown in several studies to decrease recurrence rates in the short term. Several biomaterials
have been used, including StratticeTM and Alloderm, which have shown to reduce hernia
recurrence rates (1520 %). The introduction of an absorbable Bio-A mesh (Gore) in
paraesophageal hernia repair has shown similar outcomes to StratticeTM and Alloderm,
increasing its utilization in crural reinforcement. This study aims to compare costs of these
three meshes in relation to the outcomes in terms of length of stay and recurrence, and
determine whether cost difference should be a determining factor in the type of mesh used.
Methods: We performed a retrospective analysis of patients from our institution who
underwent PEH repair with mesh between December 2004 and June 2014. Previously
published analysis have shown that absorbable mesh has a lower radiologic recurrence rate
than primary repair, but recurrence does increase with time in mesh repair patients.
However, symptom resolution is maintained in mesh patients, leading to its increased use
for PEH repair. For our analysis, we compared the cost of individual meshes and outcomes
in terms of length of stay and recurrence at 1 year follow-up. Statistics were calculated
using IBM SPSS 20.0.0.0.
Results: 227 patients underwent PEH repair with mesh. Alloderm was used in 157,
StratticeTM in 35 and Bio-A in 35. Patient groups were matched for confounding factors.
Recurrence rates and outcomes were similar in all groups. Overall recurrence rate was
12 %. No erosions or complications were observed with the use of any mesh. No statistically significant difference was observed with the hospital length of stay. Individual mesh
costs were as follows: StratticeTM was $1202, Alloderm was $783 and Bio-A was $483.
The average operative costs were $7000 for StratticeTM, $6400 for Alloderm and $5890
for Bio-A. 6570 % of the cost difference between the three types of repairs was incurred
by the cost of mesh alone, with the remainder attributable to the surgery itself.
Conclusion: Our study shows that while the outcomes of the three mesh groups were
similar in a matched patient cohort, there was a significant difference in the mesh cost,
increasing the overall operative cost. While surgeon and hospital preference still plays a
role in choosing the type of mesh used, knowledge of the individual mesh cost will help
surgeons make more informed decisions in the future.

Simran K Randhawa, MD, Lawrence N Cetrulo, MD, Walter Capote,

BA, Tuong C Nguyen, Pak S Leung, MD, Amit R Joshi, MD, FACS,
Einstein Healthcare Network
Background: Laparoscopic ventral hernia repair (LVHR) has multiple advantages when
compared to open repair. However, patients continue to report early post-operative pain. In
an effort to minimize post-operative pain, we used polyester composite mesh pre-soaked in
bupivacaine, and observed its mitigating effect on pain by measuring postoperative narcotic
requirements.
Methods: We conducted a retrospective review of all patients undergoing outpatient LVHR
using composite intra-abdominal polyester mesh by a single surgeon over three years.
Patients were divided into two groups: those who underwent conventional LVHR with
mesh and those who underwent LVHR with bupivacaine-soaked mesh. The amount of
anesthetic solution absorbed by the mesh was estimated using weight-based calculations.
Immediate post-operative narcotic requirement (total opioid dose) was calculated and
compared using a t-test.
Results: A total of 40 patients underwent elective outpatient LVHR with polyester mesh
from 20132015, of which plain mesh was used in 29 patients and soaked mesh in 11
patients. Baseline and operative characteristics were similar in the two groups. The volume
of anesthetic taken up by the mesh averaged 0.034 cc/cm2 mesh. This was equivalent to
70 % of the solution applied to the mesh topically. In the recovery room, mean oral and
intravenous narcotic use were not significantly reduced in the target group (15.2 mg from
17.9 mg of oral oxycodone equivalent/patient, p = 0.223)
Conclusion: Introduction of mesh soaked in local anesthetic did not significantly reduce the
immediate post-operative narcotic requirement after LVHR. Development of novel agents
should be studied in the future using prospective randomized trials to reduce post-operative
pain after LVHR.

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P342

Endo-Laparoscopic Inguinal Hernia Repair in Female Patients:

Benefits and Results

Does BPH Symptom Scoring Correlate with Difficulty Urinating

After Hernia Surgery?

Sujith Wijerathne, Eva Lourdes, Wee Boon Tan, Davide Lomanto,

Prof, Minimally Invasive Surgery Centre, Department of Surgery,
National University Health System, Singapore

Jacob Hebert, MD, Shoichiro A Tanaka, MD, William S Richardson,

MD, Ochsner Clinic

Introduction: Groin hernia are relatively uncommon in females. Laparoscopy is an

attractive approach in female groin hernia repair as it offers reduced surgical trauma, faster
recovery and it has the added advantage of intra-operative diagnosis and treatment of
incidental synchronous hernia which are mostly femoral hernia.
Methods: We prospectively collected data from female patients with groin hernia.
Demographic profile, hernia laterality, type of hernia, EHS-classification, operative-time,
complications, recurrence and time for recovery were collected and analyzed.
Results: 38 female patients with a mean age of 37.2 years (range 2281) underwent 47 (29
unilateral and 9 bilateral) groin hernia repairs performed using the laparoscopic approach.
36(94.7 %) primary hernia and 2(5.3 %) recurrent hernia after open repair were reported.
Out of 47 hernia, 25(53.2 %) had indirect hernia, 6(12.8 %) had direct, 7(14.9 %) had
femoral and 9(19.1 %) had mixed hernia. TEP approach was used in 33(86.8 %) and TAPP
approach was used in 5(13.2 %) patients. A standard 10 9 15 cm Polypropylene mesh was
used in 42(89.4 %) hernia and fixation done with absorbable tackers. 5(10.6 %) hernia were
repaired using an anatomical mesh without any fixation. No intraoperative complications
were reported, 1(2.6 %) patient had post-operative seroma. Mean pain score was VAS: 2.3
at 24hrs and 1 at 48hrs. No recurrences reported at 24 months follow-up.
Conclusion: TEP or TAPP approach can be identified as the preferred surgical modality for
groin hernia repair in females due to low complication rate and recurrence and concurrently
help in diagnoses of missed hernia.

Introduction: Difficulty urinating after hernia surgery effects many patients and can lead to
bladder catheterization, increasing length of hospital stay and patient dissatisfaction. Our
aim was to identify patients at risk so that we could consider prophylactic intervention.
Methods: This was a retrospective chart review. Adult male patients undergoing open or
laparoscopic inguinal hernia repair were given the American Urologic Association BPH
Symptom Score Index Questionnaire (Likert scale 05 for emptying, frequency, intermittency, urgency, weak stream, straining, nocturia and total score). The scores were correlated
with length of postoperative stay calculated from the time of OR finish until discharge from
the hospital. Urinary interventions were recorded.
Results: 27 patients filled out the questionnaire. All patients were operated on in 2014 and
15. Average age was 62 (range 3485). There were 15 laparoscopic bilateral, 4 laparoscopic
unilateral, 4 open unilateral and 2 laparoscopic repairs. 2 repairs were done with umbilical
hernia repair. Average length of postoperative stay was 229 minutes (range 106748). 9
Patients stayed over 4 hours and 4 patients stayed under 2 hours. The vast majority of
patients staying over 4 hours was for difficulty urinating. No patients in this group were
catheterized and one had a bladder scan. There was a negative trend of correlation between
age and length of stay but this was not significant. The average total BPH score was 8.8
(range 025). There was no correlation with individual or total preoperative symptom
scores and postoperative length of stay. The closest was intermittency with a p value of
0.479.
Conclusion: Although BPH symptoms scores are easy to obtain they do not correlate well
enough to use as a means of predicting postoperative urinary difficulty or for intervention.
Age also does not seem to be a reasonable means of identifying patients at risk.

P341
P343
Eras Protocol Implementation in Complex Hernia Repair Results
in Significant Cost Reduction
Kariuki Murage, MD, Braden Paschall, Paul Szotek, MD, Indiana
University Health
Introduction: Complex ventral hernia repair often results in lengthy ICU and hospital stays
that ultimately result in excessive cost to the system. Recently, Enhanced Recovery After
Surgery (ERAS) have been increasingly utilized without changes in outcomes in many
surgical subspecialties. ERAS protocols are based on multimodal pain control and intestinal
recovery acceleration. In an effort to improve our process, we elected to implement an
ERAS protocol in our complex ventral hernia program.
Methods and Procedures: A retrospective review of prospectively collected complex
ventral hernia patients was performed on a cohort from February 2012 to August 2015. In
order to analyze the data, we developed a outcomes dashboard for our institution that can be
used to compare cost and other parameters within our institution as a single institution
quality measure. The ERAS protocol consisted of:
Pre-op: Entereg 12 mg and Gabapentin 300 mg PO
Intra-Op: Experel/Bupivicaine TAP block,
Post-Op:
POD#0 Dilaudid PCA, Tylenol 650 mg PO Scheduled, Gabapentin 300 mg TID, Oxycodone 5 mg prn, and Entereg 12 mg BID until discharge
POD#1Add Naproxen 500 mg PO AM & 250 mg PM, Limited Clears, D/C Foley,
Ambulate
POD#2Add Clear Liquid Diet & Hep Lock IV
POD#3Reg Diet and disposition.
Results: In June 2015 we implemented the ERAS protocol in our series of 53 patients. 4
patients have been managed by ERAS at this point. Utilizing the IU Surgical Materials
Dashboard, we evaluated the ICU Length of stay, the hospital length of stay, and the facility
cost of repairs. The implementation of the ERAS protocol produced a significant decrease
in the average ICU LOS from 3.75 to 0.75 Days, the average hospital LOS from 9.3 to
3.25 days, and a decrease in average facility cost from $37,000 per case to $22,000 per
case. Based on the cost data we analyzed, it would have cost our hospital system
approximately $48,000 more in facility costs in one month and an estimated savings of
$660,000 had we used the ERAS protocol for all case of complex hernia repair.
Conclusion: ERAS implementation results in a significant decrease in ICU days, LOS, and
facility costs. ERAS protocols can safely be used in complex abdominal wall repair and
result in a significant cost savings to the healthcare system.

123

Short-Term Results of Ten Hernia Defect Closure Cases During

Laparoscopic Ventral Hernia Repair
Kanyu Nakano, MD1, Hitoshi Idani2, Shinya Asami1, Hiro Okawa1,
Masashi Yoshimoto1, Atene Ito1, Kazuteru Monden1, Yohei Kurose1,
Masayoshi Hioki1, Tatsuhiro Ishii1, Hiroshi Sadamori1, Satoshi Ono1,
Norihisa Takakura1, 1Fukuyama City Hospital, 2Hiroshima City
Hospital
Background: We underwent laparoscopic ventral hernia repair for 95 patients in our
hospital from April 2002 to September 2015. 27 men and 68 women, average age
71.2 years old. We conduct transfascial suture with non-absorbable thread and tacking
fixation under 3 ports. Occult hernia was found in 23 of 95 patients (24.2 %). Conversion to
an open repair was required in five cases because of massive adhesion into the hernia sac or
large hernia. The mean operation time was 123 minutes. The complications were three
seromas which needed treatment, bleeding four, two intestinal injury, two ileus, one mesh
infection, one severe asthma attack and upper gastrointestinal bleeding, one port-site
recurrence, and one liver damage. During a median follow up period of 57 months,
recurrence was noted on three patients (3.4 %).
Method: We conduct the hernia defect closure for 10 patients for the prevention of a
seroma, mesh infection, a recurrence and bulging, for hernia orifice transverse diameter
8 cm or less from October, 2013.
Results: The patients consisted of 4 men and 6 women with a mean age of 73.0 (4693)
years old. The mean operation time was 144 minutes. We used Parietex Composite mesh
for seven cases and Symbotex for two cases. We conducted only a hernia defect closure and
did not use mesh for one patient.
There was one case that fixation of the mesh was not possible enough because working
space became small after a hernia defect closure. We experienced another case that oral
intake did not advance to by the pain of the defect closure site postoperatively. Other than
them, the complications with the hernia defect closure were absent. The observation period
is short; up to 23 months, but the recurrence does not show it currently.
Conclusion: There is not the major problem about the short-term prognosis about the hernia
defect closure, but it is necessary to observe course about the long-term prognosis carefully.

Surg Endosc (2016) 30:S325S500

S413

P344

P346

Single Incision Laparoscopic Transabdominal Preperitoneal

Mesh Hernioplasty for Complicated Inguinal Hernia

Role of Multi-Detector Computed Tomography (MDCT) Based

Component Separation Index (CSI) In Management of Large
Ventral Hernias by Component Separation Technique

Kazuo Tanoue, MD, PhD, FACS, Hidenobu Okino, MD, PhD,

Masamitsu Kanazawa, MD, PhD, Kiichiro Ueno, MD, PhD, Ueno
Surgical Hospital
Background: Transabdominal preperitoneal mesh hernioplasty (TAPP) for inguinal hernia
has been popular surgical method. Recently, single incision laparoscopic TAPP repair (STAPP) has also spread in Japan. Herein, we report the assessment of S-TAPP for cases of
complicated inguinal hernia compared with simple inguinal hernia.
Patients and Methods: A consecutive series of 200 patients (73 male, 7 female) who
underwent S-TAPP during June 2010 to June 2015 in a single institution. We evaluated
operation time and morbidity of 15 cases of complicated unilateral hernia, which was
defined as (1) a recurrent hernia (n = 7), (2) hernia associated with a previous prostatectomy (n = 2), or (3) an incarcerated omental or bowel hernia (n = 6), compared with 147
cases of simple unilateral hernia.
Establishment of the ports: A 25-mm vertical intra-umbilical incision is made for port
access. One 5-mm optical port and two 5-mm ports were placed side-by-side through the
umbilical scar.
Surgical procedure: The procedure was carried out in the conventional fashion with a wide
incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and
an appropriate placement of polypropylene mesh (3DMaxTM light, Bard) with fixation
using the tacking device (AbsorbaTack, Covidien). The hernia sac is usually reduced by
blunt dissection, or is ligated and transected with ultrasound activated device. The peritoneal flap is closed by one suture with 30 PDS and the 67 tacks using AbsorbaTack.
Results: Seven patients were treated for a recurrent hernia that had been repaired previously by the McVay procedure (n = 3) or with a mesh plug (n = 2), 3DMax mesh (n = 1),
or UltraPro Hernia System (n = 1). Two patients were treated for hernia associated with a
previous prostatectomy, and six patients were treated for incarcerated omental or bowel
hernia. Operation times were consistently greater for the complicated hernias than for the
simple hernias, but the time differed significantly only between prostatectomy-associated
hernia and simple hernia (p = 0.02). None of the complicated hernias required conversion
to traditional laparoscopic repair. Seroma developed after surgery in three patients with a
complicated hernia. The incidence of seroma was higher in the complicated hernia group
than in the simple hernia group, but the difference was not significant.
Discussion: Our results suggest that S-TAPP is a safe and feasible method without additional risk, even in complicated hernias. However, further evaluation for postoperative pain
and long-term complications compared to S-TAPP mesh hernioplasty for simple hernia
should be required.

P345
Incisional/Ventral Hernia Repairs in the Morbidly Obese: New
Technique for an Old Problem
Francis Baccay, MD1, Ki Won Kim, MD1, Colin Dunn2, Jai P Singh3,
Irene J Lo4, 1Montefiore Medical Center/Albert Einstein College
of Medicine, 2Albert Einstein College of Medicine, 3SUNY Upstate
Medical Center, 4West Coast Surgical Associates, Inc
Introduction: The occurrence rate of incisional/ventral hernias after laparotomies has been
reported to be as high as 11 %1. Every surgery has risks and complications; however,
patients with higher body mass index (BMI) are at higher risk of complications. Morbid
obesity is a risk factor for ventral hernias, both as a feature of their occurrence and as a
factor contributing to recurrence after repair. Using multiple symmetrically placed suture
lines with direct mid-line fascial graft reinforcement, we report our experience with this
technique.
Methods and Procedures: A total of 90 consecutive patients with incisional/ventral hernias were repaired. Patients without medical clearance as well as patients with umbilical
hernias were excluded. All patients, including those with higher BMI, underwent repair
without regard to pre-operative weight loss. All hernias were repaired using open bilateral
component separation and biologic grafts placed in a retro-rectus position, either preperitoneal or intra-peritoneal.
Results: There were no recurrences, re-admissions or mortalities. Mean follow-up was
38.4 months (766 months), mean age was 56.7 years old (3784 years old), and mean
BMI was 42.6 kg/m2 (30.5 - 58.6 kg/m2). Mean hernia size was 390 cm2 (248610 cm2)
and mean length of stay was 4.68 days (2 - 8 days). Wound infection rate was 3.3 % (3/90).
Post-operative mean weight loss was noted to be 15.6 % (11.3 % to 17.5 %).
Conclusions: With the rise in prevalence of obesity, most general surgeons will have to
face the problem of the obese patient with an abdominal wall defect. Treatment of these
bariatric patients raises unique challenges, and at this time, there is still no consensus on the
best treatment option. In this series, we demonstrate excellent outcomes in safety and
efficacy using this technique of multiple symmetrically placed suture lines with direct midline fascial graft reinforcement.2 Larger prospective trials comparing outcome with other
laparoscopic or open techniques are warranted.

Deborshi Sharma, Prof, Vinay Upadhyay, Dr, Romesh Lal, Prof, Dr,
Lady Hardinge and Dr RML Hospital
Introduction: Laparoscopic Ventral Hernia Repair has lower recurrences when defect is
closed and overlapped with mesh. In large complex ventral hernias, tension free closure of
defect is not possible. Component separation (CS) can facilitate tension free closure of
defect. Pre-operative prediction, regarding need of CS for tension free closure of defect is
the present need.
Aim: Assess ability and efficiency of MDCT based component separation index (CSI) in
deciding necessity for component separation during repair of large ventral hernias.
Materials and Methods: Thirty patients with clinical diagnosis of ventral hernia underwent MDCT and CSI was calculated (CSI = Angle of diastases/360). Group I (First 15
patients) - Open Group. Per-operative assessment was done for tension free closure of
defect and CS performed if required. CSI value above which complete defect closure
necessitated component separation was taken as the CSI reference point. Group II (Next 15
patients) - Laparoscopic Group. Patients with CSI at or below reference point of group I,
directly underwent laparoscopic defect closure with IPOM. The other cases with CSI value
above the reference point of group I, first had endoscopic assisted laparoscopic component
separation (LCS) before entry into peritoneal cavity for defect closure and IPOM.
Results: In Group I, defects with CSI above 0.067 required CS for closure, while in Group
II, CSI above 0.044 could only be closed completely without LCS. Further in open
approach, defect with CSI [ 0.25 and in laparoscopy group CSI [ 0.125, defect closure
was not possible even after CS or LCS respectively.
Conclusion: CSI is a more comprehensive parameter for evaluation of ventral hernia than
conventional two-dimensional parameters of defect and can predict the need of component
separation prior to tension free closure of defect in both laparoscopic and open approach. In
Laparoscopy complete defect closure is possible with lower CSI values compared to open
approach.

P347
Management of Cholecystis National Centre NouakcottMauritania
Ahmedou Moulaye IDRISS, Faculty of Medicine Nouakchott
University
Aims: The authors report a retrospective descriptive study of 256 patients with cholecystitis. The aim of study was to assess care and the profile of cholecystitis in general surgery
department at the National Hospital Centre in Nouakchott Mauritania
Patients and Methods: Over a period of 3 years (Jan 2011Dec 2013)256 files were
included. Databases were statistically analyzed by SPSS and the variables studied were:
age, gender, ethnicity, history, clinical biology, Imagery, Surgery, length of stay.
Results: There were 219(85.5 %) women and 37(14.5 %) men. Mean age 47y (1490). The
arab ethnic group dominant (97 %). History: Hypertension (5.5 %), Diabetics (4 %), cardiopathies (2.3 %) and others (8 %). Clinically RUQ pain was the most frequent symptom.
Definite diagnosis was (95 %). Severity assessment criteria was mild 80 %, moderate
(19 %) and severe (1 %). Laparoscopy cholecystectomy was performed in 166(65 %),
conversion (12 %) and 2(0.8 %) cases bile duct injury. Morbidity was 5.2 % and mortality
was 2(0.8 %). The average length of hospital stay was 4.31 days (123 d). The pathology
was found for 163 (64 %) patients with (49. %) of acute cholecystitis and (51 %) 0f chronic
cholecystitis
Conclusion: Cholelithiasis is common Mauritania, its early care needed to avoid the
occurrence of complications and reduce the percentage of deaths.

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P349

The Comparison of Oncologic and Clinical Outcomes

of Laparoscopic and Open Liver Resection for Hepatocellular
Carcinoma

Laparoscopic Assisted Trans-Abdominal Anterograde Portal

Vein Catheterization: A Novel Approach to the Portal Vein
in a Porcine Model

Hong-Jin Kim, MDFACS1, Dong-Shik Lee, MD1, Keun Soo Ahn2,

Koo Jeong Kang2, 1Department HBP Surgery, Yeungnam University
Hospital, 2Department HBP Surgery, Kei-Myung University Hospital

Pierre Allemann, MD1, Pierre Bize, MD2, Michele Diana, MD3,

Nicolas Demartines, MD2, Jacques Marescaux, MD3, Alban Denys,
MD1, 1Department of visceral surgery, Lausanne University Hospital
(CHUV), Switzerland, 2Department of interventional radiology,
Lausanne University Hospital (CHUV), Switzerland, 3Institute
for image-guided surgery (IHU), Strasbourg, France

Purpose: We evaluate the operative outcome and oncologic outcome of laparoscopic liver
resection for hepatocellular carcinoma (HCC), and compare with open liver resection.
Method: From January 2004 to February 2013, clinical data of 120 patients who underwent
laparoscopic liver resection for HCC (Laparoscopic liver resection group, lapa-group) were collected from two medical centers in Daegu and analyzed retrospectively. Control group (Open liver
resection group, open-group) were retrospectively matched, and compared with lapa-group.
Results: Laparoscopic major liver resections were performed in 6 patients. Laparoscopic
anatomical resections and non-anatomical resections were performed in 65 patients, and 55
patients, respectively. Mean operative time was shorter in lapa-group, mean intraoperative transfusion rate and total amount were small in lapa-group. In lapa-group and open-group 5-year disease
free survival rate (DFS) were 40.0 0.08 %, and 47.5 0.06 %, respectively. (p-value = 0.773)
In lapa-group and open-group 5-year overall survival rate (OS) were 65.9 0.8 %, and
65.1 0.6 %, respectively. (p-value = 0.479)
Conclusion: Laparoscopic liver resection for HCC is feasible and safe in a large number of
patients, with reasonable operative and oncologic results.

Introduction: Anterograde access to the mesenterico-portal venous system is necessary for

advanced interventional procedures like for example portal vein recanalization in chronic
obstruction. Open ileocolic vein dissection is the standard approach, exposing fragile patients to
complications (ascitis, infections and adherences), especially in cirrhotic ones. The aim of this pilot
study was to develop a combined laparoscopic and percutaneous access to the mesenterico-portal
vein system.
Methods: Experiments were performed in a hybrid surgical-radiological suit, under sterile conditions. Five female pigs aged 6 months and weighing between 41 to 45kgs were studied. Under
general anaesthesia, laparoscopic dissection of the cranial mesenteric vein was performed. Under
endoscopic guidance, the vein was catheterized percutaneously (Fig. 1). Complete 3D portography
were obtained using CT-scan imaging and portal contrast injection. After catheter retrieval,
haemostasis at the puncture site was obtained with selective laparoscopic 5.0 Prolene suture
(Fig. 2). Animals were kept alive for two weeks and two additional portal accesses were attempted
from the same vein, after 7 and 14 days, using the same technique.
Results: Access to the portal vein was feasible in all animals (success rate 100 %). The mean
access time was 15 +/-3 min. No immediate complications were observed. Particularly, no intraoperative or postoperative haemorrhages were detected. Second-look at 7 and 14 days were all
successful. No adhesions were observed and the vein was accessible and patent in all animals.
Portography demonstrated the absence of complications related to the previous catheterization.
Conclusion: This experimental study shows that a laparoscopic assisted trans-abdominal anterograde portal vein catheterization is feasible, reproducible and can be repeated in the same animal.
This novel approach may potentially offer some advantages compared to the open approach.

Fig. 1 External view

Fig. 2 Internal view

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P352

Management of Large Pancreatic Cystic Tumor During

Laparoscopic Distal Pancreatectomy

Optimal Management of Gall Stone Ileus: Diagnosing by CT Scan

and a Limited Operative Approach

Hodaka Moriyama, MD, Koji Asai, Manabu Watanabe, Hiroshi

Matsukiyo, Tomoaki Saito, Tomotaka Ishii, Ryohei Watanabe,
Toshiyuki Enomoto, Natsuya Katada, Yoshihisa Saida, Shinya
Kusachi, Toho university Ohashi Medical Center

Emil Bota, MBBCh1, Hesham M Souka, MD, FRCS, MBBCh2,

1
Diana Princess of Wales Hospital, Grimsby, UK, 2Amina Hospital,
Ajman, UAE

Management of large pancreatic cystic tumor during laparoscopic surgery is mandatory due to the
prevention of the cystic rupture. Herein, we present the usefulness of a double-balloon catheter
(SAND balloon catheter; Hacco Co, Tokyo, Japan) in laparoscopic distal pancreatectomy (Lap-DP)
in the case of large pancreatic mucinous cystic neoplasm (MCN).
The case was 70-yeaer-old woman, who presented with abdominal distention, and was referred to
our hospital for further examination and treatment. Imaging revealed a cystic lesion more than
20 cm in diameter extending from the pancreatic body to tail, leading to a diagnosis of MCN.
Laparoscopic finding revealed that sufficient surgical field could not be obtained because of the
large pancreatic cystic lesion. After dissection of cystic surface, SAND balloon catheter was
inserted in it and more than 3,000 ml fluid was suctioned out. No leak of intra-cystic fluid was
observed. This procedure improved the surgical field, and enabled us to safely perform Lap-DP.
Postoperative course was uneventful, and the patients was discharged on postoperative day 10.
In conclusion, we were able to safely perform Lap-DP for large MCN using the double-balloon
catheter. Our results demonstrated this catheter is a useful instrument for the treatment of large
pancreatic cystic tumors without leakage into the abdominal cavity.

P351
Correlation of Fibroscan with Liver Biopsy in Malignant Biliary
Obstruction
Naren K A, MS, Thakur D Yadav, MS, Vikas Gupta, Mch, SGE,
Ashim Das, MD, Virendra Singh, MD, Saroj K Sinha, DM, PGIMER
Chandigarh
Objectives: The Objective was to see the sensitivity and specificity of fibroscan in detecting biliary
cirrhosis secondary to malignant biliary obstruction. A secondary objective was to correlate
fibroscan with liver biopsy, so as to avoid the invasive liver biopsy in future.
Methods and Procedures: In our study all the patients with unresectable disease underwent a
percutaneous core liver biopsy (under local anesthesia) and in resectable patients undergoing
Surgery (under General Anesthesia), a core biopsy of the normal liver parenchyma was taken as a
part of the primary procedure planned. The staging system (ISHAKs Modified Histological
Activity Index) was used to assess the severity of fibrosis Fibroscan was performed in all the
patients The probe was placed at the intercostal space overlying the liver with the patient in supine
position in right arm abduction. Ten validated measurements were taken, with the median value
taken as the final result, The values thus measured in these studies were then categorized into
different LSM Fibrosis stage.
Results: Our study showed that Fibroscan is a very sensitive tool in picking up High stage (3 and 4)
fibrosis and thus influence treatment management in such patients. In our study the Sensitivity of
Fibroscan in detecting Stage III and IV fibrosis was 100 % with the specificity at 64.2 %. Prolonged cholestasis also influences Fibroscan and hence overpredicts the Fibrosis stage. In our study,
2/5 patients of stage III and 5/9 patients of Stage II biopsy proven fibrosis were overpredicted by
fibroscan. About 77 % of them had cholestasis in the Histopathological report. As there is no
universality in the reference range used for measuring and grading liver fibrosis by Fibroscan
(Disease to Disease variation), an Universal consensus should be arrived at, for implementation of
common reference ranges which can be projected onto the population for general use.
Conclusion: Our study showed that Fibroscan is a very sensitive tool in determining the Liver
Fibrosis especially in high grade fibrosis (Stage III and Stage IV). Documentation of Cirrhosis
(Stage IV) or a pre cirrhotic stage (Stage III) by Fibroscan helps us offer a less radical surgery for
patients with Malignant Obstructive Jaundice and hence reduces post op Morbidity and Adverse
Liver events. Also it is easily measurable and reproducible and hence Fibroscan offers a noninvasive alternative to Liver biopsy, thereby avoiding its various complications.

Aim: To establish a standard management protocol in the modern era of cross sectional imaging
and targeted laparoscopic approach.
Methods: We report 14 patients with gall stone ileus treated over the last 7 years. This is a DGH
with 130,000 populations operating on around 300 gall bladders a year. We have a policy operating
only on symptomatic gallstones.
Results: All gallstones were more than 2.5 cm in diameter. Twelve patients were females. Average
age 73 years (range 4693). A retrospective history consistent with attacks of cholecystitis was
present in twelve patients. Complete intestinal obstruction was the presentation in all 14 patients.
All 14 patients had their gallstones recognized on pre-operative CT scan with pneumobilia. Eleven
patients have associated significant multiple co-morbidities. All 14 patients had operations to
relieve the obstruction by enterotomy, removal of the stone and closure. Three patients had a
laparoscopy-assisted delivery of the affected segment, the others had various incisions. All went
home well with average length of stay of 16 days (range 450), only one patient had post operative
wound infection needing prolonged dressings. Two stones were in the jejunum 4 in the ileum and
the rest in unspecified location of small intestine. Two stones were impacted at site of obstruction.
All patients were well during follow up at least for a year after the operation. One patient died
2 years following surgery at age of 86 (bed ridden, needed 50 days hospital stay before returning to
his nursing home). Only one patient had persistent symptoms that can be due to the remaining gall
bladder. Only the first patient in the series had concomitant cholecystectomy and postoperative
duodenal leakage giving a collection that was treated with NBM, TPN, antibiotics and radiological
drainage with no further recurrence.
Conclusion: Therapy should be aiming towards relieving the obstruction not dealing with the gall
bladder. Cross sectional study has an important role in establishing the diagnosis and planning
laparoscopic assisted surgery. The patients that are likely to develop the condition are those with
large cast stones more than 2.5 cm in diameter, associated with co-morbidities and repeated attacks
of low-grade cholecystitis.

P353
Staging Laparoscopy in 111 Intra-Hepatic and Hilar
Cholangiocarcinoma Patients: A Tertiary U.K. Referral Centre
Experience
Nicholas T.E. Bird, Mr, Mohamed Elmasry, Mr, Robert Jones, Mr,
Declan Dunne, Michael Kelly, Dr, Johnathan Evans, Mr, Graeme
Poston, Professor, Stephen Fenwick, MD, Hassan Malik, MD,
University Hospital Aintree
Aims: Staging laparoscopy is part of the routine management of cholangiocarcinoma for determining if there is occult intra-abdominal metastatic disease not discernible on cross-sectional
imaging. The aim was to determine the utility of staging laparoscopy in the largest retrospectively
assessed British cohort of hilar and intra-hepatic cholangiocarcinoma patients resected at a large
U.K. tertiary Hepato-Biliary centre.
Methods: A database of 111 cholangiocarcinoma patients undergoing staging laparoscopy over an
8 year period from May 2007 to June 2015 was retrospectively analysed. The efficacy of staging
laparoscopy in terms of Yield, Positive-Predictive-Value, False-Discovery-Rate and Specificity of
the test was then calculated.
Results:

Laparoscoped

Exploratory laparotomy

N (Total)

111

80

Male:Female

63;48

47;33

Disease precludes further surgery

30

16

Peritoneal metastases

15

11

Intra-hepatic mets

Locally advanced

Poor liver quality

Resection

64

Yield precluding further surgery

27 % (30/111)

20 % (16/80)

The Positive-Predictive-Value of laparoscopy was 80 % (64/80).

The False-Discovery-Rate (1-PPV) was 20 %.
The Specificity of laparoscopy was 65.2 % (30/46).
42.3 % of patients with laparoscopically occult peritoneal metastases proceeded to laparotomy.
47/64 (73.4 %) resections had cholangiocarcinoma; 14/64 (21.9 %) benign disease; 3/64 (4.7 %)
other tumours of which 2/64 (3.13 %) were neuroendocrine and 1/64 (1.6 %) were hepatocellular
in origin.
Conclusions: The high Positive-Predictive-Value of 80 % indicates that staging laparoscopy is
highly precise in confirming radiologically resectable intra-hepatic and hilar cholangiocarcinoma.
However, the relatively low Specificity of the test of 65.2 % indicates that in borderline
resectable cases laparoscopys utility is more limited.

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Minimally Invasive Central Hepatectomy for Gallbladder Cancer

is Safe and Effective

Management of Laparoscopic Partial Hepatectomy for Cranial

and Dorsal Lesions in our Department

Georgios V Georgakis, MD, PhD, David L Bartlett, MD,

Amer H Zureikat, MD, Herbert J Zeh, MD, Melissa E Hogg, MD,
MS, University of Pittsburgh Medical Center, Division of Surgical
Oncology

Sena Iwamura, Satoshi Kaihara, Yukiko Kumada, Shoichi Kitano,

Kita Ryosuke, Hideyuki Masui, Hiromitsu Kinoshita, Yusuke
Sakamoto, Motoko Mizumoto, Masato Kondo, Junji Komori, Hiroki
Hashida, Hiroyuki Kobayashi, Kenji Uryuhara, Ryo Hosotani, Kobe
City Medical Center General Hospital

Introduction: Minimally invasive surgery (MIS) continues to grow within surgical oncology. With
the robotic platform, complex surgeries can be done safely and effectively through small incisions.
Gallbladder cancer is very rare and liver resection with portal lymphadenectomy is the only
curative therapy. The introduction of MIS in the treatment of the gallbladder cancer has not been
studied. We aim to evaluate outcomes of patients with gallbladder cancer undergoing MIS compared to open central hepatectomy.
Methods and Procedures: Using the institutional cancer registry and surginet databases, we
retrospectively reviewed patients who underwent a central hepatectomy with portal lymphadenectomy for gallbladder cancer from 20112014. Gallbladder cancer patients with metastatic
disease, undergoing chemoperfusion, or without definitive surgery were excluded. Surgeries were
analyzed by MIS, robotic (14) and laparoscopic (3), compared to open (17) surgery.
Results: There was no difference in BMI, but MIS patients were younger than open patients (64
versus 76 years respectively; p = 0.0043). No difference in mean operative time was seen in MIS
versus open cohorts: 185.1 and 241.7 minutes respectively (p = 0.23). The mean EBL was less in
MIS versus open cohorts: 144.2 ml and 350.3 ml respectively (p = 0.006). Increased operative
time was correlated with increased blood loss in the both cohorts (MIS: p = 0.01; Open:
p = 0.0009). Peri-hepatic drains were placed less frequently in MIS (29.4 %) compared to open
cohorts (76.5 %; p = 0.01). R0 resection rate was 88.3 % in both cohorts (p = 1.0). ICU
admission postop for the MIS and open cohorts was 29.4 % for both groups (p = 1.0). No difference in diet initiation was noted with a median postoperative day 3 for both (p = 0.24). MIS
cohort were converted to oral pain medications quicker (median 2 versus 3 days respectively;
p = 0.022) and discharged home earlier (median 4 days versus 6 days; p = 0.018), than the open
cohort. There was no postoperative 30-day mortality and complication rates were 52.9 % in both
cohorts (p = 1.0). Clavien 1 and 2 complications were seen in 52.9 % (MIS) and 47.1 % (open). In
the open cohort there was one bile leak and one re-operation for a fascial dehiscence (Clavien 3).
There was a trend, but no statistically significant difference in median overall survival between the
two groups (MIS: not reached versus open: 20 months; p = 0.092).
Conclusion: Our data suggest that the minimally invasive, especially the robotic, approach to liver
surgery is a safe and equally effective technique for the management of the gallbladder cancer with
improvement in blood loss and length of stay.

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Background and Aim: Although laparoscopic partial hepatectomy (LPH) is becoming popluar,
resection of cranial and dorsal lesions has a high degree of difficulty and is associated with massive
bleeding, insufficient surgical margins and breaching of tumor. We show you our management that
? using intraoperative echo frequently to ensure the margin of the tumor, ?keeping the operative
field dry by pre-coagulation dissection technique (PCD technique) using IO electrode before
resection of parenchyma by CUSA to recognize a fine vasculature, and ?considering introduction of
hand-assisted laparoscopic surgery (HALS LPH) and small laparotomy (Hybrid LPH) actively.
Among 48 cases of LPH undergone until September 2015 in this policy, there were 13 cases of
LPH for S7/8 lesions. We show you the perioperative results and videos of them.
Results: Indications for LPH were two cases of HCC and 11cases of metastasis of colorectal
cancer. There were two cases being undergone with other surgery simultaneously (2 cases of
resection of colorectal cancer, 2 cases of stoma closure and a case of others). Number of tumors
was 9 cases of single tumor, 2 of 2 tumors and 2 of 3 tumors. All cases had Child-Pugh class A liver
function (10 cases of 5 points and 3 of 6 points). 12 cases had been nave for hepatectomy, and a
case was re-hepatectomy. The mean operating time spent for liver resection was 290 minutes and
the mean amount of bleeding was 55 ml. We perform Pure LPH for 7 cases, HALS LPH for 4
cases, and conversion to laparotomy was 2 cases (because of bleeding, adhesion). The early days,
HALS LPH and conversion to laparotomy was often seen, but recently it has become possible to
undergo pure LPH as possible. We performed Pringle maneuver for 6 cases. Only one case had
Grade 2 postoperative complication in Clavien-Dindo classification (use of antibiotics because of
sustained high inflammatory reaction). Median postoperative length of stay was 9 days.
Conclusions: We can undergo LPH for cranial and dorsal lesions safely.

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The Retroperitoneal Resection Margin: An Independent

Prognostic Factor in Periampullary Carcinoma

Percutaneous Transhepatic and Transjejunal Rendezvous

Procedure for Treatment of Complete Dehiscence
of the Bilioenteric Anastomosis

Mohanasundaram Avudaiappan, MS, Thakur D Yadav, MS, Vikas

Gupta, Mch, Ashim Das, MD, Rakesh Kochhar, DM, Saroj K Sinha,
DM, Anupam Lal, MD, PGIMER, CHANDIGARH
Introduction: The retroperitoneal resection margin is most common margin microscopically involved by tumor in
resectable periampullary carcinomas. The aim of the study was to evaluate outcome in patients who have undergone
pancreaticoduodenectomy in terms of retroperitoneal resection margin is an independent prognostic factor in periampullary carcinoma. The aim of the study is to determine: 1) The total incidence of positive SMA margin in resected
pancreaticoduodenectomy specimen. 2) To see how it correlate with the type of periampullary carcinoma (head of
pancreas, distal bile duct, duodenal and ampullary).
Methods and Procedures: 46 patients of periampullary adenocarcinoma undergone surgery were included in our
study. Two senior surgeons were involved in the study denude at least 4 cm of SMA and they had followed the same
protocol for all patients. The SMA margin marked with methylene blue. Specimen cut and origin of the tumour
documented on the table by surgeon. A detailed gross examination of the specimen carried out. At first, the components of the specimen assessed and then the exact location of the tumour identified i.e. ampullary, pancreatic head,
distal cholangio, duodenal. The bile duct resection margin, pancreatic resection margin and the retroperitoneal
resection margin sampled. The reteroperitoneal margin was identified directly adjacent to the proximal 34 cm of the
SMA. Samples of multiple areas of tumour including the adjacent non-tumorous areas submitted for paraffin section
(5-BO section). Pathologic evaluation of the specimen includes: 1) Histology of tumour, 2) Differentiation, 3) Origin
of tumour, 4) Vascular, lymphatic and perineural invasion-presence or not, 5) The status of resection margins of
common bile duct, pancreatic margin and the retroperitoneal margin, 6) lymph node status. We had done minimum
followup of five months after surgery. 34 patients completed minimum postop period of 5 months followup. Two
patients had lost in followup Associations between histological factor evaluated by chi-square test. Survival curves
were calculated by the Kaplan Meier method.
Results: In our study cholangiocarcinoma (34.8 %) was the predominat component of periampullary carcinoma.
Retroperitoneal margin was involved in six (13 %) cases. Among that three cases were cholangio carcinoma and three
cases were carcinoma head of pancreas. Mean survival of these patients is 11.58 months, Patients with retroperitoneal
margin positive had mean survival of 7.5 months, comparing to mean survival of 11.39 months of retroperitoneal
margin negative patients. Among all cases carcinoma head of pancreas had poor survival with mean survival of
7.7 months.
Conclusions: In our study we had found that, 1) Cholangiocarcinoma was the most common type of periampullary
carcinoma. 2) Carcinoma head of pancreas had the poor survival comparing to the other periampullary malignancies.
3) Retroperitoneal margin involvement was the independent poor prognostic factor for survival.

Martin G Rosenthal, MD, Adam Rogers, MD, Travis Edelstein, DO,

Abubaker Ali, MD, Ziad T Awad, MD, FACS, University of Florida
College of Medicine, Jacksonville
Introduction: Pancreaticoduodenectomy (PD) is the standard of care for patients with resectable malignant diseases
of the periampullary region. Leaks from the hepaticojejunostomy (HJ) are estimated to range between 28 %.
Although leaks from the pancreaticojejunostomy (PJ) are more common than those from the HJ the impact of these
complications can be equally severe, and the management nearly as complex. Despite this, biliary leaks from the HJ
following PD has been underreported in the literature compared to leaks from PJ. Interventional radiologists (IR) have
become a critical part of the team caring for patients with complications following PD. We report on a patient in whom
PD was complicated by a complete disruption of the HJ anastomosis treated percutaneously by a novel IR intervention.
Case Report: A 31 year old female with a significant history of Familial Adenomatous Polyposis and Gardners
syndrome presented for evaluation of multiple, diffuse, duodenal polyps, including the periampullary region that were
found to harbor low grade dysplasia. The patient underwent a PD in the standard open fashion. On post-operative day 5
the patient became unstable and was transferred to the Intensive Care Unit. She was found to have a biliary leak related
to a complete dehiscence of the HJ anastomosis. Percutaneous transhepatic cholangiography (PTC) was performed
demonstrating a complete dehiscence of the HJ. Retrograde transjejunal access was obtained percutaneously and
subsequently a guidewire was advanced via this access and snared through the PTC access for definitive internal/
external drainage via an antegrade approach. Serial cholangiograms demonstrated a progressive decrease in the
severity of the bile leak as well as decreased output from the perihepatic percutaneous drains. The final cholangiogram
performed two months after the initial operation demonstrated no residual leak and free flow of contrast through the
previously dehisced hepaticojejunostomy.
Discussion: According to the International Study Group on Pancreatic Fistula model our patient had a grade C bile
leak which was successfully treated via an antegrade percutaneous transhepatic-transjejunal approach. To our
knowledge this is the first case to describe the utilization of IR to salvage a completely disrupted HJ anastomosis
following PD, therefore, avoiding the high morbidity associated with reoperation. The field of IR is rapidly expanding
with numerous applications that have been proven to provide a less invasive approach in managing post-surgical
complications.
Conclusion: Complete dehiscence of the hepaticojejunostomy anastomosis can be successfully managed with a novel
IR intervention reducing the morbidity of reoperation.

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P361

Single-Incision Laparoscopic Cholecystectomy by an Abdominal

Wall Lifting Method

Laparoscopic Liver Resection for Hepatocellular Carcinoma

in Child-Pugh Class B Cirrhosis

Hirotsugu Ohara, MD, Fujieda heisei Memorial Hospital

Osamu Itano, MD, PhD, FACS, Masahiro Shinoda, MD, PhD, Minoru
Kitago, MD, PhD, Yuta Abe, MD, PhD, Taizo Hibi, MD, PhD,
Hiroshi Yagi, MD, PhD, Chisato Takagi, MD, Yuko Kitagawa, MD,
PhD, FACS, Department of Surgery, Keio University School
of Medicine

Background: Since 1994, We have performed 400 cases of laparoscopic cholecystectomy (LC)
with good results by an abdominal wall lifting method using our original lifting bars. The bar
consisted of a bent stainless steel rod 5 mm in diameter. Our lifting method is suitable for not only
cardiopulmonary compromised patients but also the patients with severe inflammation. Singleincision laparoscopic cholecystectomy (SILS) has recently emerged as a less invasive alternative to
standard multi-incision LC. We have tried to perform SILS by using our lifting method. This
method, including the cost assessment of laparoscopic instrument, will be discussed.
Method: Ten patients underwent SILS between April 2015 and April 2017. One patient showed a
negative cholecystogram in preoperative intravenous cholangiography. After placement of wound
protector to umbilical incision, two lifting bars were inserted and drawn by winches into positions,
that were to the bilateral side of the patient. A mini-loop retractor introduced subcostally was used
to retract the GB and visualize Calots triangle. All these operations were performed with conventional straight laparoscopic instrument.
Results: Only one cases was converted to three - port surgery in liver chirrosis case, but no cases
were converted to conventional open surgery. The mean operation time was 97.1 min, and the
estimated blood los was 18 ml. The postoperative course was uneventful in all cases.
Conclusion: We didnt have to use the specific multi-channel port and the disposable roticulater,
which were expensive. Furthermore, we were able to perform SILS without sacrificing safety. Our
lifting method is reasonable and reliable in SILS, too.

P359

Background: There have been several reports confirming that laparoscopic liver resection for
hepatocellular carcinoma (HCC) is safer and more feasible than open liver resection in patients
with cirrhosis. However, the patients in most studies had mild cirrhosis and few reports have
focused on patients with severe cirrhosis. Here we evaluated the feasibility of laparoscopic liver
resection for HCC in patients with Child-Pugh class B cirrhosis.
Methods: We retrospectively reviewed the data of 70 patients who underwent partial hepatectomy
or left lateral sectionectomy for HCC until December 2014 in our institution. The patients were
divided into three groups according to liver function: Child-Pugh class B (Cirrhosis B), Child-Pugh
class A cirrhosis (Cirrhosis A), and Child-Pugh class A non-cirrhosis (Non-cirrhosis). The perioperative outcomes were compared among the three groups.
Results: There were no significant differences in age, sex, or distribution of hepatitis cause. The
Cirrhosis B group showed statistically higher total bilirubin level, lower serum albumin level, lower
prothrombin time, higher indocyanine green retention rate at 15 min, and higher a-fetoprotein level
than the Cirrhosis A and Non-cirrhosis groups. The operative outcomes including operative time,
blood loss, transfusion rate, mortality and morbidity rates, and postoperative hospital stay were
comparable among the three groups.
Conclusions: Laparoscopic liver resection for HCC in patients with Child-Pugh class B cirrhosis is
as feasible as that in those with Child-Pugh class A liver cirrhosis or no cirrhosis.

Liver Regeneration after Open and Laparoscopic Left Partial

Hepatectomy Considering the Fungal Translocation
to the Remnant Liver
Konstantinos S Mammas, MD, MSc, PhD1, Nikolaos Kavantzas, MD,
PhD2, Georgia Kostopanagiotou, MD, PhD1, Ismene Dontas, DVM,
PhD3, Vasileios Smyrniotis, MD, PhD3, George Arsenis, MD, PhD3,
Eustratios Patsouris, MD, PhD2, 1National and Kapodistrian
University of Athens-Surgical Laboratory Professor K.TOUNTAS,
2
National and Kapodistrian University of Athens- Medical School,
Department of Pathology, 3National and Kapodistrian University
of Athens
Introduction: In liver resection It has been shown that the degree of bacterial translocation
increases by operative trauma. The liver regeneration after Open (OLPH) and Laparoscopic Left
(LLPH) Partial Hepatectomy (PHx) of a porcine experimental model is compared by measuring the
known molecules implicated in the regenerating process and the candida species translocation to
the remnant liver.
Methods and Procedures: Two pairs of double-series of twenty-nine liver tissues taken from
twenty nine porcine livers, after OLPH or LLPH (PD0) and on the 7th postoperative day (PD7),
were randomly allocated into two groups: the OLPH (n1 = 19 9 2) and the LLPH (n2 = 10 9 2).
The liver tissue sections in each group, had been prepared and stained with PCNA, Gaspase-III and
anti-Ubiquitin respectively. Then a PCNA based proliferative index (LCPI), a Gaspase-III based
Apoptotic Index (LCAI), and an Ubiquitin based intracellular stress index (LISI) were prospectively estimated by microscopic visualization. Additionally an anti-VEGF stain based angiogenesis
index (LCANGI) based on a sample of twenty eight tissue sections (n1 = 8 9 2, n2 = 6 9 2) and
a PAS-stain based Candida species remnant liver lobule colonization index (CRLLCI) of another
sample of twenty eight tissue sections (n1 = 7 9 2, n2 = 7 9 2) were estimated by microscopic
visualization retrospectively. The LCPI, LCAI, LISI, LCANGI and CRLLCI indexes were compared between OLPH and LLPH on PD0 and on PD7 time-points.
Results: Statistical comparisons of LISI resulted in a statistically significant difference, favoring
the OLPH on PD0 (p \ .1). LCPI was statistically significantly higher after OLPH than LLPH on
PD7 (p = .002). LCANGIOLPH was statistically significantly higher than LCANGILLPH, on PD7
(p = .028). No difference was found in the apoptotic level between OLPH and LLPH on PD0
(.926) and on PD7 (p [ .313). The CRLLCI was significantly higher in the OLPH in comparison
with the LLPH group, on PD0 (p = 0.158) and on PD7 (p = .006).
Conclusions: In the porcine model: 1. In the context of liver regeneration after PHx, the increased
intra-cellular stress in the remnant liver after OLPH seems to trigger a comperatively increased
liver cell proliferation in comparison to LLPH on PD7. 2. Candida species translocation to the
remnant liver found significantly increased after OLPH than after LLPH on both PD0 and PD7
time-points.

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P362
LDP Vs ODP for Pancreatic Adenocarcinoma: A Retrospectively
Comparative Study
Yi-ping Mou, MD, FACS1, Miao-zun Zhang, MD2, Xiao-wu Xu,
MD1, Ren-chao Zhang, MD1, Jia-fei Yan2, Wei-wei Jin1,
1
Department of General Surgery, Zhejiang Provincial Peoples
Hospital, Hangzhou, China, 2Department of General Surgery, Sir Run
Run Shaw Hospital, School of Medicine, Zhejiang University,
Hangzhou 310016, Zhejiang Province, China
Background: Laparoscopic distal pancreatectomy (LDP) showed advantage of perioperation
outcomes over open distal pancreatectomy (ODP) for benign and low-grade tumor of the pancreas.
But LDP for pancreatic ductal adenocarcinoma (PDCA) was not widely accepted. We designed a
retrospectively comparative study to analysis the oncological efficacy of Laparoscopic distal
pancreatectomy or open distal pancreatectomy for PDCA.
Methods: From 2003.6 to 2015.3, 70 patients consecutively underwent elective LDP or ODP for
PDCA. The two groups demographic information, perioperative outcomes and survival data were
compared.
Results: 25 patients underwent LDP with 1 conversion to ODP and 45 patients underwent ODP for
PDAC. Baseline characteristics were comparable between the LDP and ODP groups. The intraoperative blood loss, first oral intake and postoperative hospital stay were significantly less in LDP
group than ODP group (125.2 120.3 ml vs 565.1 651.5 ml, P = 0.000; 3.2 1.1d vs
4.5 1.7d, P = 0.006; 12.8 4.4d vs 17.3 8.6d, P = 0.005). The mean operation time, overall
postoperative morbidity and postoperative pancreatic fistula rates were similar in the two groups.
There were no significant differences in tumor sizes (3.9 + 1.0 cm vs 3.7 + 1.0 cm, P = 0.570)
and number of harvested lymph nodes (11.5 7.2 vs 9.7 4.9 P = 0.214). The median overall
survival for both groups was 14.0 months.
Conclusion: LDP is technically feasible and safe for PDAC in selected patients. The short- and
long-term oncologic outcomes were similar between both LDP and ODP for PDAC.

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Laparoscopic Pancreaticoduodenectomy: A Report of 125 Cases

in a Single Institute

Lap Cholecystectomy with Ercp as a Combo Approach

for the Management of CholecystoCholedocholithiasis:
A Retrospective Study

Wei-Wei Jin, MD1, Xiao-Wu Xu, MD2, Yi-Ping Mou, MD, FACS2,
Yu-Chen Zhou2, Chao-Jie Huang2, Chao Lu1, Rong-Gao Cheng1, JiaYu Zhou1, 1Medical School, Zhejiang Universtity, 2Divison
of Gastroentropancreas, Department of General Surgery, Zhejiang
Provincial Peoples Hospital
Background: Laparoscopic pancreaticoduodenectomy is still a difficult procedure for most
surgeons and is uncertainty in safety, feasibility and oncologic outcomes. This study aims to
present a big series of laparoscopic pancreaticoduodenectomy in a single institution.
Methods: From September 2012 to August 2015, there were 125 patients undergoing
laparoscopic pancreaticoduodenectomy in a single institution. The blood loss, operative
time, postoperative morbidity, length of postoperative hospital stay and 30-day mortality
were analyzed.
Results: There were 116 patients undergoing pure laparoscopic pancreaticoduodenectomy
and the other 9 patients with laparoscopic assisted procedure. The mean age was
(60.24 12.21) years old and BMI was (23.21 3.54) kg/m2. The operative time was
(354.44 62.93) minutes and the blood loss was (176.45 142.54) ml. The rate of overall
postoperative complications was 34.4 % (43/125), with 9.6 % (12/125) of grade B or C
pancreatic fistula and 9.6 % (12/125) of postoperative bleeding. The mean postoperative
hospital stay was (16.71 9.88) days. There was no 30-day mortality. The mean size of
tumors was (3.92 2.59) cm. The number of lymph nodes retrieved was (20.95 11.97).
There were 85 patients with malignance, including pancreatic adenocarcinoma (n = 37),
cholangiocarcinoma (n = 14) and ampullary adenocarcinoma (n = 34), the tumor size was
(2.63 1.41) cm, (2.81 1.24) cm and (3.12 1.93) cm, respectively. The number of
lymph nodes retrieved was (22.04 11.77), (20.81 9.19) and (23.47 12.31),
respectively. The rate of R0 resection was 94.8 % (2/28), 100 % and 100 %, respectively.
Conclusion: Laparoscopic pancreaticoduodenectomy is technically safe and feasible in
skilled hands, and can achieve good oncological outcomes.

Dr Sreejoy Patnaik, MS, SHANTI MEMORIAL HOSPITAL

PVT.LTD
Background: In the management of Cholecysto-choledocholithiases, Laparoscopic
Cholecystectomy and ERCP is today emerging as an alternative the treatment of choice.
Other Modalities of treatment existing include Pre- & Post-operative ERCP, Laparoscopic
CBD Exploration trans-cystic approach, Laparoscopic Choledochotomy, Open CBD
exploration.
Material and Methods: Retrospective study on 200 patients. Period of Study - 6 yrs.
(2008- 2014). Criteria of the Study: All patients of Gallstones with CBD stones proven by
USG. CBD stone size \1 cm. Gallstones with raised ALP / LFT. Pre-operative Endoscopy
were carried out in all the patients to exclude any upper GI pathology. Patients with
concomitant Pancreatitis were ruled out. MRCP was not taken into consideration due to its
non-availability during this study.
Results: This Combo procedure was found to be: Cost effective, Time saving, Decreased
risks of anesthesia, Over all patient satisfaction, Shortened hospital stay
Conclusions: Obstructive calculus biliary disease can effectively be treated by surgeons in
a One Step fashion. By limiting the number of operative procedures and hospital days,
patients can be safely and more efficiently treated using this method. We found a significant
difference in total hospital charges. Therefore the implementation of this combo approach
(LC-ERCP) outweighs the two steps or sequential procedure & may be an alternative
approach in the management of Obstructive calculus biliary disease. For treatment ofcholecystocholedocholithiasis, synchronous LC combined with ERCP reduces incidence of
complications, decreases length of hospital stay, simplifies the surgical procedure, and
reduces the duration of operation.

P367
P364

Parenchymal Dissection Technique in Laparoscopic Hepatectomy

Management of the Hyperkinetic Gallbladder in Adults: A Case

Series

Satoshi Kaihara, MD, PhD, FACS, Kenji Uryuhara, MD, PhD, Junji
Komori, MD, PhD, Sena Iwamura, MD, Ryo Hosotani, MD, PhD,
Kobe Medical Center General Hospital

Lawrence N Cetrulo, MD, Amit Joshi, MD, FACS, Albert Trang,

MD, Einstein Healthcare Network
The primary indications for laparoscopic cholecystectomy are stone related diseases in
adults. A subset of patients who require surgery carry a diagnosis of biliary dyskinesia,
usually defined as an ejection fraction on Cholecystokinin hpeatobiliary iminodiacetic acid
exam (CCK-HIDA). In children, the primary indication for laparoscopic cholecystectomy is
biliary dyskinesia. However, not only do patients have low ejection fractions, but a significant number have hyperactive ejection fractions, with and EF [ 80 %. There is well
established research showing long term resolution of symptoms in children with hyperkinetic ejection fractions on CCK-HIDA. Here we will discuss a case series of adults
receiving laparoscopic cholecystectomy for hyperkinetic biliary dyskinesia.
Four patients presented for biliary colic with workups revealing no signs of disease secondary to gallbladder sludge or stones. The only positive finding was an elevated ejection
fraction on CCK-HIDA. These patients all had resolution of their symptoms immediately
after surgery and at subsequent follow up visits 4 weeks after surgery. This disease process
requires further analysis but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Introduction: One of the crucial points in laparoscopic hepatectomy is how to manage the
intraoperative bleeding during the parenchymal dissection. In the dry field we can precisely
realize the fine anatomical structures in the liver parenchyma and treat the intrahepatic
vessels properly. For this purpose we established new hepatic-parenchymal dissection
technique with pre-coagulation using VIO system followed by parenchymal crushing
using CUSA so called pre-coagulated dissection technique (PCD technique). Here we
introduce this technique and the results.
Patients and Methods: Fifty two consecutive patients, performed laparoscopic hepatectomy using PCD technique in our hospital from June 2012 to September 2015, were
included in this study. Original disease was HCC in 15 cases, metastatic liver tumor in 32
cases, and benign tumor in 5 cases. Pure laparoscopic operation was performed in 34 cases,
hand assisted in 12 cases, and hybrid in 6 cases. Operation mode was lateral segmentectomy
in 16 cases and partial resection in 36 cases. For the parenchymal dissection, 1st assistant
coagulated the cutting area first using VIO system (soft coagulation mode, power 60 W,
effect 5) and the operator crushed this pre-coagulated tissue using CUSA. With this method
we encountered little bleeding during the parenchymal dissection and could realize the fine
anatomical structures in the liver parenchyma. Glissonian and hepatic veins were dissected
using various methods according to the size. Pringle maneuver was applied only to the
complicated resection.
Results: Operation time was 109 to 424 minutes (mean; 252 minutes) and intraoperative
blood loss was 0 to 642 ml (mean; 91 ml). One liver cirrhosis case needed intraoperative
blood transfusion. Post-operative peak AST was 235+/-324 IU/L and T-Bil was 1.3+/1.0 mg/dL (mean+/-SD). One case suffered from PHLF by ISGLS Grade B. The patient
with Clavian-Dindo classification Grade 3a was 2 cases (cerebral infarction, intra-abdominal abscess), who recovered without any severe prognostic symptoms. All patients
discharged hospital with good condition 3 to 14 days (mean; 6.6 days) after the operation.
Conclusions: The pre-coagulated dissection technique was effective to reduce the intraoperative bleeding and the incidence of post-operative severe complications.

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P371

Safety of Midline Three Ports Laparoscopic Cholecystectomy

in Difficult Gall Stone Disease

Laparoscopic vs Open Distal Pancreatectomy

for Adenocarcinoma: A Single-Institution Comparative Study

Ahmed Hussain Pathan, Dr, Ashfaque Ahmed Bhurgri, Dr, LUMHS

PAKISTAN

Ariel Ferraro, MD1, Maria Clotilde Gancedo, MD1, Javier Crisci2,

Fernando Dip, MD1, Alejandro Rolle, MD2, 1BUENOS AIRES
UNIVERSITY, 2Sanatorio Parque. Rosario

Objective: To determine the safety profile of midline three ports laparoscopic cholecyctectomies in difficult gallstone diseases at Liaquat university hospital Hyderabad /
Jamshoro.
Patients and Methods: The descriptive case series study was conducted in Hepatopancreatobilliary and minimal access surgery at Liaquat University Hospital Hyderabad /
Jamshoro. All the patients with 3570 years of age of either gender presented with gallstone
disease were managed laparoscopically. The frequency and percentage was calculated for
categorical variables and mean SD was calculated for numerical variables. As this was
descriptive case series so there was no any statistical test of significance was applied.
Results: During two year study period total 500 patients were presented with gallstone
disease with means age 58.85 5.93 (SD). Eighty five patients (400 females and 100
males) were underwent midline three port laparoscopic cholecystectomy procedure. The
mean postoperative hospital stay after laparoscopy was 1.5 days while no any complication
was observed in study participants.
Conclusion: It has been concluded that midline three port laparoscopic cholecystectomies
procedure is safe and has no complications in difficult gall stone disease.

P369
LAPAROSCOPIC CBD Exploration; 15 Years Experience
Duncan Light, Yousef Aawsaj, Liam Horgan, Northumbria
Healthcare NHS Foundation Trust
Background: The treatment of common bile duct stones remains controversial with debate
between endoscopic cholangiopancreatography (ERCP) and common bile duct exploration.
A recent meta-analysis has shown no significant difference between these approaches,
however there is a trend in the literature to favour a single stage procedure in the form of
laparoscopic common bile duct exploration. We report our experience over a 15 year
period.
Methods: All cases of common bile duct exploration were identified from 2000 to 2015 and
analysed retrospectively from a large NHS Foundation Trust in Northumbria. There were
no exclusions.
Results: 296 patients were included who underwent laparoscopic common bile duct
exploration. 203 were female and 93 were male. The mean age was 60 years (range 16 to
84 years). 231 procedures were performed electively and 65 as an emergency. 10 procedures were successfully performed as day cases. 11 procedures were converted to an open
procedure due to adhesions or a difficult dissection (4 %). 63 procedures were performed
with a transcystic approach with a mean post op stay of 2 days (range 0 to 7). 233 procedures were performed with a choledocotomy with a mean post op stay of 6 days (range 3
to 14 days). Stone clearance was successful in 255 patients (86 %). A subsequent ERCP
was performed for the remaining 41 patients. 3 patients returned to theatre for early post
operative bleeding (1 %). 16 patients had persistent bile leaks following a choledocotomy
(5 %). 9 were managed conservatively, 4 patients were taken for a laparoscopy and 3
patients had an ERCP with a biliary stent placed. There was no significant difference
between a continuous or interrupted closure of the choledocotomy. No patient developed
recurrent stones on follow up.
Conclusion: Laparoscopic bile duct exploration can be performed successfully in both the
emergency and elective setting. Daycase surgery is feasible in selected patients. A transcystic approach should be favoured where possible.

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Background: Laparoscopic distal pancreatectomy (LDP) is performed increasingly for

pancreatic pathology in the body and tail of the pancreas. Few reports in the literature
evaluate the comparison between the open and laparoscopic approach for malignant lesions
of the body and tail of the pancreas. We Evaluate the technical aspects and oncological
outcomes of the laparoscopic and open approach for adenocarcinoma of the body and tail of
the pancreas
Methods: Between 20122013 twenty five distal pancreatectomies were performed. An
initial series of 8 patients with distal pancreatic adenocarcinoma that underwent distal
laparoscopic or open pancreatectomy was compared and prospectlevely analized. Complication rate, blood lost, tumor size, margin resections, number of nodes dissected, free
survival rate and and recurrence was evaluated in the laparoscopic and open approach .Data were analysed using SPSS() v19 utilising standard tests. A p value \ 0.05 was
considered significant.
Results: Out of 25 patients who underwent distal pancreatectomy between 2012 and 2014,
8 had histologically confirmed adenocarcinoma (LDP n = 4, ODP n = 4). No difference
was founded between both groups when size of tumor was compared. (LDP 27.7 vs. ODP
31.25 mm, p [ 0.05). Complete resection (R0) was achieved in all cases. No difference in
the number of lymph nodes was informed between both groups. (LDP 11.75 vs. ODP 11.25,
p [ 0.05). No intraoperative complication was reported. Blood loss was 232 ml in the ODP
group compared 175 in the LDP group. A longer operative time was noted for LDP (305 vs.
257 min, p \ 0.05). Patient were discharged before in LDP compared to the ODP (LDP5.5
vs ODP 7.25 days, p \ 0.05). No leaks were founded in any of the 8 patients evaluated.
Overall disease free survival rate also was similar in both groups. (LDP 28.25 vs ODP
27 months, p [ 0.05)
Conclusions: Laparoscopic treatment of distal adenocarcinoma seems to have the same
oncological outcomes when compared to the open procedure. Even though the laparoscopic
approach prolonged the operative time we founded a decrease in the blood lost and hospital
stay.

P372
Single Incision Laparoscopic Liver Resection: Safety, Feasibility
and the Role of Stapler Technique in Parenchymal Resection
Hong Yu, Shuodong Wu, Xiaopeng Yu, Diaobo Yao, Shengjing
Hospital of China Medical University
Introduction: Single incision laparoscopic hepatectomy (SILH) has rarely been reported
due to the technical challenge of liver parenchymal resection and the risk of bleeding.
Stapler technique of parenchymal resection, which has been successfully performed in
conventional laparoscopic hepatectomy, has not been evaluated in SILH.
Methods: Data on SILH from January 2010 to December 2013 were extracted and analyzed. Surgical procedure, operating time, blood loss, hospital stay, and cost were analyzed.
The data of single incision left lateral sectionectomy (SILLS) with different techniques of
parenchymal resection were compared.
Results: A total of 33 SILH were analyzed. The mean operating time was 128 min and the
intraoperative blood loss was 203 ml with the hospital stay 8.8 d. For SILLH with different
techniques of parenchymal resection (energy device vs stapler), the operating time and
blood loss in stapler group was significantly less than those in energy devices group.
Conclusions: SILH is safe and feasible in selected patients. Stapler technique is more
favorable in SILH for resection of liver parenchyma compared with energy device. More
clinical studies are needed to further evaluate the role of stapler technique in SILH.

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P373

P375

Management of Postoperative Bile Leak: Tertiary Centers

Experience

Functional AND Morphological Outcome Of Patients Undergoing

SURGERY For Chronic Pancreatitis

Mohammed Omar, Alaa Redwan, Sohag university

Anil Mani, Dr, Vikas Gupta, Dr, Thakur D Yadav, Dr, Rakesh
Kochhar, Dr, Naveen Kalra, Dr, Bikash Medhi, Dr, Post Graduate
Institute Of Medical Education and Research, Chandigarh, India

Background: Bile duct leak is an infrequent but serious disorder. The great majority occurs
after hepatobiliary surgery. Early recognition and adequate multidisciplinary approach is
the cornerstone for the optimal final outcomes. Traditionally, surgery has been the gold
standard for the management of bile leak, but it is associated with significant morbidity and
mortality. Biliary endoscopic procedures have become the treatment of choice, as simple,
noninvasive procedure, with low morbidity and mortality, short hospital stay, and coast
effective, with demonstrated results comparable to those achieved with surgery.
Purpose: A prospective and retrospective work to evaluate management of postoperative
bile leak.
Patients and Methods: In the period from Jan. 2005 to Dec. 2014, a random sample of 311
patients (153 females and 158 males) with postoperative bile leak from general surgery
departments, and gastro-intestinal endoscopy units, Sohag and Assiut University hospitals
were studied and evaluated.
Results: The definitive management of bile leak was done within 0143 days (median
8 days). Patients were managed accordingly using, endoscopy in 232 patients (plus percutaneous techniques in 8 patients) and surgery in 79 patients. Endoscopic treatment proved
very effective in 94.2 % of the patients with simple bile leak and 44.3 % of the patients
with complex bile leak.
Conclusion: Endoscopic treatment substituted surgery in all simple bile leak cases as a
competitive treatment. Surgical treatment was the definitive treatment of complex bile leak;
however endoscopy was a mandatory complementary tool in initial management.

Introduction: This study was conducted to evaluate the functional (exocrine, endocrine,
pain relief and quality of life) and morphological outcome of patients undergoing surgery
for chronic pancreatitis.
Methods and Procedures: 39 patients underwent surgery (Frey n = 27, others n = 12).
Preoperative assessment was done on admission. Exocrine function was evaluated using
fecal fat globule estimation and endocrine function using HbA1c estimation. Quality of life
was measured using EORTC-QLQ C30 questionnaire. Pain relief was measured on basis of
need for analgesics and decrease in VAS score. Postoperatively patients were followed up
at or after 3 months. MRI was done at follow up to evaluate the morphological outcome.
Results: Exocrine insufficiency was detected in 76.92 % of patients postoperatively (new
onset - 41 %). Endocrine insufficiency was detected in 33.3 % (new onset - 23 %). The
mean BMI increased from 19.96 3.11 to 20.98 1.94 (p-value - 0.005). The mean
weight gain was 3.10 9.38 kg. The mean serum albumin level increased from
4.29 .067 to 4.6 .067 (p-value - 0.041). The pain relief was 89.74 %. Quality of life
improved from 30.77 21.47 to 69.23 21.13 (p value -\0.001). The mean MPD
diameter decreased from 7.7 2.66 to 3.44 1.44 mm (p-value \0.001). There was no
correlation of parenchymal thickness and duct to parenchyma ratio with exocrine
insufficiency.
Conclusions: Surgical treatment offers good pain relief, substantial improvement in quality
of life and remarkable nutritional status improvement in chronic pancreatitis even at the
cost of some amount of exocrine and endocrine function deterioration.

P374
Comparison of Quality of Life After Single Stage vs Two Stage
Management of Patients with Concomitant Gall Stones
and Common Bile Duct Stones: A Prospective Randomized
Control Trial

P376

Virinder K Bansal, Krishna Asuri, Sunita Suman, Omprakash

Prajapati, Pramod Garg, Rajesh Sagar, Mahesh C Misra, All India
Institute of Medical Sciences

Evaluation of the Efficacy and Accuracy of Intraoperative

Cholangiograms in Patients with Suspected Choledocholithiasis

Introduction: Various prospective and retrospective studies have compared LCBDE and
ESE a`LC and reported similar morbidity, mortality and cost effectiveness. However, no
literature exist regarding Quality of life (Qol) in these patients. The present randomized trial
was undertaken to compare the outcome and Qol of patients undergoing treatment with
these two approaches.
Materials and Methods: The study was conducted from 1st March 2013 to 31stMay 2015.
26patients were randomized to single stage laparoscopic CBD exploration with cholecystectomy (Group I) and 27 to ERCP followed by laparoscopic cholecystectomy (Group II).
Diagnosis was confirmed preoperatively using MRCP and/or endoscopic ultrasound. Outcome measures included the Qol scores assessed via WHO BREF, EORTC QLQ c30 and
HADS questionaires and pain scores.
Results: The demographic and clinical profiles were similar in both the groups. The
average pain score on VAS scale was similar in both groups at 24 hours (p = 0.4), at
1 week (p = 0.35), and at 6 weeks (p = 0.2). Qol was similar in both groups with respect
to psychological well being, environment and social relationships before and after intervention as assessed by WHO BREF. There was significant improvement in these domains
post operatively (p \ 0.01). EORTC QLQ c30 also showed significant improvement in
physical, emotional and role functioning in both the groups (p \ 0.01) with no intergroup
variation pre or post procedure. Global health status was also similar in both groups post
intervention. Symptom scales also showed substantial improvement in terms of nausea and
vomiting. However, there were no significant complaints of insomnia, appetite loss or
diarrhea. Both the depression and anxiety scores were comparable between the two groups
preoperatively and at 3 months postoperatively. Two patients were diagnosed as borderline
cases of depression, in ERCP ? LC group. However, they recovered 3 months after
surgery.
Conclusions: Single stage management of patients with gall stones and CBD stones is at
par with two stage approach in terms of pain scores and quality of life scores.

Andrew J Cleland, BS1, Carrie Ronstrom, BS1, Reema Mallick, MD2,

Kevin Rank, MD3, Stuart Amateau, MD, PhD3, Mustafa Arain, MD3,
Martin Freeman, MD3, James V Harmon, MD, PhD2, 1University
of Minnesota Medical School, 2University of Minnesota, Department
of Surgery, 3University of Minnesota, Department of Medicine
Introduction: We evaluated the efficiency and efficacy of performing intraoperative
cholangiograms (IOC) to evaluate for choledocholithiasis during laparoscopic cholecystectomy (LC). We compared the preoperative data, operative data, and clinical outcomes in
24 patients who underwent IOCs to the findings in 84 patients who did not undergo IOC in a
108 patient cohort with a high likelihood of choledocholithiasis.
Methods and Procedures: This patient cohort consisted of 108 consecutive patients who
underwent both LC and endoscopic retrograde cholangiopancreatography (ERCP) within a
30-day period at our teaching hospital between July 2010 and July 2014. All patients in this
cohort had a high likelihood of choledocholithiasis based on laboratory imaging studies.
The patients who underwent IOCs were further characterized based on the findings of the
ICOs: positive or suspicious for stones (12), negative for stones (6), or IOC unable to be
completed (6). Student T-tests and ANOVA statistical assays were performed to evaluate
the statistical significance of the differences between the groups.
Results: Of all patients in this cohort, stones were found in 52 %; and sludge was found in
78 %. The presence of either stones or sludge were found in 95 % of all patients in the
cohort. The average operative time to perform LC for patients who did not undergo IOC
was 101 58 minutes; for patients who underwent LC/IOC the average operative time was
144 59 minutes, the difference was statistically significant (p = 0.0014). Clearly positive or suspicious findings were identified in half of the patients who underwent IOC.
Clearly negative IOCs were recorded in 25 % of the patients who underwent IOC. In 25 %
of patients in whom the IOC was attempted, it could not be completed. There were no
significant differences in the average peak liver function values, pancreatic enzyme values,
number or size of stones recovered, or clinical outcomes between the patient groups.
Conclusions: Even in patients with a high likelihood of choledocholithiasis, IOC was
clearly positive or suspicious for stones in only half of the patients in whom the IOC
procedure was either attempted or completed. The IOC was completed in only 75 % of the
patients in whom it was attempted. The average additional operative time to perform or
attempt the IOC was 43 minutes. Intraoperative mentoring for surgeons performing IOC
might improve the efficiency and success of this procedure at our teaching hospital. No
complications were associated with performing the IOC procedures.

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P377

P379

Effect of Partial Hepatectomy on the Seeding and Growing

of Liver Metastases in a Rat Model

Bile Aspiration Exfoliative Cytology in Cases of Malignant

Obstructive Jaundice

Ivan V Fedoriv, MD1, Ignacio Garcia-Alonso, PhD2, Mikel GonzalezArribas, Student2, Inigo Cearra, MD2, Asier Santamaria, Student2,
Borja Herrero de la Parte, MSC2, 1Department of human anatomy,
operative surgery and topographic anatomy IFNMU, IvanoFrankivsk, Ukraine, 2Dpt. of Surgery and Radiology. Faculty of
Medicine UPV/EHU. Leioa, Spain

Thakur Yadav, MS, DNB, Krishnamurthy Jagadeesh, MS, Radhika S,

Vikas Gupta, Rakesh Kochhar, postgratuate institute of medical
education and research chandigarh

Introduction: Partial hepatectomy (PH) is the best therapeutic option for patients with liver
metastases. However, liver resection causes the release of growth factors (GF), which can promote
the proliferation of the tumoral cells still present in the patient. In this study we have evaluated the
effect of PH on the growth of liver metastases after intrasplenic cell inoculation.
Methods and Procedures: Under isofluorane anesthesia, a midline laparotomy was performed for
clamping the left lateral lobe artery (LLA) of 18 WAG/RijCrl male rats. After that, tumour
induction was done by seeding 250.000 syngeneic CC-531 cells into the spleen; five minutes later
splenectomy was performed in all animals and after another 10 minutes the clamp of the LLA was
removed and, in the PH-group, the left lateral lobe of the liver was excised (9 rats). Thereafter, the
abdominal cavity was close.
Three weeks after cell seeding, the animals were examined using ultrasound (US) to evaluate
tumour progression; 7 days later, all the animals were sacrificed and the liver was removed and
placed in paraformaldehyde. Each lobe was cut into 1 mm sections to measure metastasis and total
hepatic surface.
Results: All animals inoculated with CC-531 cells developed liver metastases. The percentage of
liver surface covered with metastases was statistically significantly higher in the animals that were
subjected to partial hepatectomy, compared to animals which were not hepatectomised
(46.98 8.76 % vs. 18.73 5.65 %; p \ 0.05). The right lateral lobe (RL) showed no difference
in both hepatectomised and no hepatectomised animals (45.38 11.24 % vs. 32.69 10.19 %;
p [ 0.05). The paramedian (PL) and caudate lobe (CL), showed significant differences in liver
surface occupied by metastases in both groups of animals.
Finally, analyzing the left lateral lobe (LL) surface of non-hepatectomized animals occupied by
metastases, it may be seen that it is statistically significantly lower than any of the other lobes, only
7.28 2.55 %.
Conclusions: In this experimental model, the process of seeding & growth of colorectal cancer
cells in the liver clearly benefits from the growth factors produced following partial liver resection.

Background: Bile withdrawn for cytology during ERCP and PTBD is a safe method with no
increasing in patients morbidity. As it is routinely done in patients of malignant obstructive
jaundice and allows a diagnostic orientation in many of the patients.
Aim: To analyse the diagnostic value of biliary exfoliative cytology in suspected cases of
malignant obstructive jaundice.
Objectives: Histopathology of the tumour/Tissue diagnosis which includes FNAC and Biopsy is
considered gold standard in all patients, bile aspiration cytology results of PTBD and ERCP group,
positive for atypical cells/malignant cells will be held in comparison with the same in the end of the
study. In patients without tissue diagnosis PET-CT or MRCP + Tumour markers are considered as
gold standard.
Results: Out of the total 81 patients, there were 43 cases of carcinoma gallbladder, 24 cases of
cholangiocarcinoma, and 14 cases of periampullary carcinoma. Finally 68 patients were considered
in final analysis as 54 cases had tissue diagnosis, ten cases had PET-CT and four cases had
MRCP + tumour markers respectively as per our gold standard. 57 patients underwent PTBD and
11 patients had ERCP; following which bile sample was sent for exfoliative cytology.
16/57(28.07 %) patients tested positive for malignant/atypical cells in PTBD group. 9/11(81.82 %)
patients tested positive for malignant cells in ERCP group. ERCP samples yielded a sensitivity of
90 %; specificity 100 %; positive predictive value 100 %; & Diagnostic accuracy 90 %. PTBD
samples yielded a sensitivity of 29 %; specificity remaining at 100 %; positive predictive value
100 %; & Diagnostic accuracy 31.57 %.
Conclusion: Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (PPV 100 %) and with minimal costs. This becomes more relevant when tumour
is either locally advanced or metastatic and a tissue diagnosis is required to start either neo adjuvant
or definitive chemotherapy. But the tissue diagnosis along with tumour markers is costly, time
consuming and cumbersome for the patients. Henceforth biliary exfoliative cytology really serves
the purpose in getting tissue diagnosis which can determine the course of management.

P378

P380

Laparoscopic Versus Open Liver Resection for Small

Hepatocellular Carcinoma: A CaseControl Study

Endo-Lap Technique to Preserve Gallbladder for Benign

Gallbladder Diseases

Wipusit Taesombat, MD, Bunthoon Nonthasoot, MD, Boonchoo

Sirichindakul, MD, Jade Supaphol, MD, Methee Sutherasan, MD,
Supanit Nivatwongs, MD, Department of Surgery, King
Chulalongkorn Memorial Hospital, Chulalongkorn University,
Thailand

Zhen-Ling Ji, MD, PhD, Zhongda Hospital, Southeast University

School of Medicine

Introduction: Laparoscopic liver resection (LR) is considered an alternative procedure to open

liver resection (OR) with respect to safety and feasibility. However, the suitable indication for
obtaining benefits of laparoscopic technique is remained challenging. The aim of this study was to
compare peri-operative and survival outcomes between two techniques in patients with small
hepatocellular carcinoma (HCC).
Methods: Between January 2007 and January 2013, twenty-seven patients underwent LR were
retrospectively matched to 29 patients underwent OR by age, body mass index, underlying liver
disease, Child-Pugh classification, ASA physical status, preoperative alfa-fetoprotien level, tumor
diameter and extent of liver resection. Peri-operative and long-term outcomes were compared
between both groups.
Results: The mean tumor diameter in LR was 3.8 1.6 cm and OR was 3.9 1.7 cm (p = 0.9).
On the first postoperative day, the mean level of white blood cell count (mean, 9,083.2 2,495.9
vs 16,491.9 18,570.9 cell/mm3, p = 0.001), serum AST (171.9 119.3 vs 252.4 113.6 U/L,
p = 0.002) and ALT (149.3 120.7 vs 218.6 116.1 U/L, p = 0.003) in LR were significant
lower than OR. The LR had length of hospital stay shorter than OR (mean, 5.9 5.6 days vs
8.2 4.4 days, p = 0.004). The morbidity was no significant difference between both groups. In
subgroup of patients with pathologically proved cirrhosis, the drainage tubes was removed earlier
in LR compare to OR (3.2 1.6 vs 4.9 2.5 days, p = 0.02). The long-term survival outcomes
were no significant difference. The 1-, 3- and 5-year disease free survival were 70.4 %, 63 % and
57.7 % in LR and 82.2 %, 66.8 % and 61.6 % in OR, respectively (p = 0.6). The 1-, 3- and 5-year
overall survival were 92.6 %, 85.2 % and 77.4 % in LR and 100 %, 88.8 % and 64.8 % in OR,
respectively (p = 0.9).
Conclusions: In patients with small HCC undergoing laparoscopic liver resection have shorter
length of hospital stay and lesser degree of liver injury than open liver resection whereas comparable peri-operative and long-term survival outcomes.

123

Introduction: Cholecystectomy is the main treatment method but is associated with various
complications in some patients. This study explores a novel, endo-lap surgery for the
removal of calculi and polyps to preserve the gallbladder using a laparoscope combined
with choledochoscope.
Methods: A retrospective analysis was conducted between January 2010 and December
2014 in 65 patients with cholecystolithiasis and 29 with polyps who underwent the endo-lap
invasive surgery for calculi /polyp removal and gallbladder preservation.
Results: In 94 cases of gallbladder preservation, the gallbladder was preserved perfectly
with no complications. The other 4 cases were switched to laparoscopic cholecystectomy
because of tiny stones blocking the cystic duct or submucosal stones. The success rate was
93.8 %. Follow-up included both clinical assessment and ultrasound examination every
6 months after the operation. The patients with preoperative symptoms were symptom-free,
and gallbladder function was well preserved. The overall stone recurrence rate was 4.94 %
at a mean follow-up of 36 months (range 660).
Conclusions: Using the laparoscope combined with the soft choledochoscope for gallbladder-preserving cholecystolithotomy can remove stones/polyps preserve gallbladder
function, and effectively avoid the various complications of cholecystectomy.
In our follow-up, gallbladder function was not affected and the stone recurrence rate was
quite low.

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P381

P382

Laparoscopic Cholecystectomy in Patient with Incidental

Intraoperative Findings of Liver Cirrhosis

Laparoscopic Management of Cystic Neoplasm of the Pancreas:

A Case Report

Michael Dennis Dela Paz, MD, AMOSUP Seamens Hospital,

Intramuros, Manila

Hector F Sanchez-Maldonado, MD, Enrique J Cedillo-Aleman, MD,

Marco A Juarez-Parra, MD, Ulises Caballero-de la Pena, MD, Ernesto
Miranda-Cervantes, MD, Hospital Christus Muguerza Alta
Especialidad / UDEM

This is a case study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with
incidental intraoperative findings of liver cirrhosis.

This is a case of a 55-years old diabetic female who had chronic intermittent right upper
quadrant abdominal pain and had a recent whole abdominal ultrasound findings of Diffuse
Fatty Liver and Cholelithiasis. She had no episode of jaundice and her physical examination
findings and ancillary laboratory results were unremarkable. Laparoscopic Cholecystectomy was done. Incidentally, the liver was noted to be cirrhotic which was pulsating and
contracting around the slightly distended gallbladder. Exposure of the critical view of safety
was done by grasping the fundus of the gallbladder and lifting it up laterally nwhich upon
slight retraction of the gallbladder from the liver bed cause bleeding on the junction of the
gallbladder and the liver. The surgeon decided to seek help to an experienced surgeon.
Together, they decided to continue the procedure laparoscopically with caution using the
dome down approach. A piece of gauze was inserted and used as a cushion that pushed the
liver superiorly to expose the gallbladder. Electrocautery near the gallbladder wall was
done using a hook to separate the gallbladder from the liver bed with immediate gentle and
suffice cauterization of ever small amount of bleeding along the liver bed. Upon released of
the gallbladder up to the infundibulo-cystic junction, the cystic duct and cystic artery were
isolated, identified and ligated using clips. Cholecystectomy was done and, upon re-examination, the liver bed was noted to be dry without any active bleeding. Post-operative, the
patient was noted to be unremarkable and was discharged after 24 hours without any
symptoms of pain nor complication of bleeding.
Laparoscopic cholecystectomy can be considered an effective and safe treatment for
gallbladder stones in selected patients. It is important that it should be attempted by surgeons with sufficient experience and skills in handling cirrhotic liver because the liver tends
to resist the proper exposure of the gallbladder as it constantly pulsate and distortedly
contracted around the gallbladder tending it to be intrahepatic. The danger of causing high
pressure bleeding along the liver parenchyma is always a possible complication so that
cautious cushioned gentle retraction and attentive gentle suffice cauterization along the
plane of dissection and the hepatic bed is needed. The patient benefited from the procedure
by reduced post-operative pain and hospital stay.

Introduction: Cystic neoplasms represent only 10 % of cystic lesions of the pancreas and 1 % of all tumors. Their
incidence has been reported to be rapidly increasing with the routine use of cross-sectional imaging.
Although majority of cystic lesions are inflammatory pseudo-cysts, the diagnosis is unlikely without the history of
pancreatitis, trauma or associated risk factors. Serous cystadenoma is a benign lesion that requires non-surgical
management if asymptomatic. Mucinous neoplasms are considered premalignant lesions and demand pancreatic
resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the
resection sample.
Between 4075 % of the patients are asymptomic or diagnosed incidentally. When symptoms are present they tend to
be nonspecific, including mass effect and abdominal pain. Although conservative management has been advocated in
small lesions; those greater than 4 cm or symptomatic, tend to harbor malignant or premalignant lesions and operative
intervention is a reasonable option.
We present the case of a distal pancreatic cystic tumor successfully treated by laparoscopy.
Case Report: A 38 y.o. female with previous history of carcinoma of the cervix successfully treated with radical
hysterectomy and adjuvant chemo-radiation. She presented with a 12 month history of diffuse intermittent lumbar
pain, physical exam was unremarkable. An abdominal CT-scan demonstrated a spongy, well-circumscribed 8 cm
lesion that contained multiples cysts separated by septa located in the tail of the pancreas. She was managed
expectantly for 6 months.
Upon surgical consultation, an elective laparoscopic distal pancreatectomy was planned due to the increased size of the
tumor and persistence of her symptoms. The tumor was found in closed relation with the spleen hilum and
splenectomy was required. Vascular control was achieved with bipolar energy and transection of the pancreas performed with vascular stapler. The specimen was removed thought a pfannestiel incision and a drain was placed. She
had an uneventful postoperative recovery. Pathology reported a microcystic serous cystadenoma.

Conclusion: The management of pancreatic cystic lesions remains controversial. Nevertheless, experts recommended surgical resection for all symptomatic pancreatic cysts not
only for the relief of symptoms but because of the higher malignant potential in this subset
of patients.
In the case of tumor in the tail, distal pancreatectomy can be performed laparoscopically
with similar or shorter operative times, blood loss, complication rates, and length of hospital
stay than the open approach and can be recommended as the treatment of choice for benign
and noninvasive lesions in experienced hands when clinically indicated.

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P383

P385

A Novel Method in Single Incision Laparoscopic Cholecystectomy

Without a Cameraman

Thoracoscopic Transdiaphragmatic Approach for Tumors

Located in Postero-Superior Segments

Ho-Seong Han, YoungRok Choi, Yoo-Seok Yoon, MD, PhD, Jae

Young Cho, MD, PhD, Jae Yool Jang, Han Lim Choi, Jae Seong Jang,
Seong Wook Kwon, Seoul National University, College of Medicine

Tomojiro Ono, Dr, Shinichi Ikuta, MD, PhD, Takayoshi Nakajima,

MD, Tukasa Aihara, MD, PhD, Naoki Yamanaka, MD, PhD, Meiwa
Hospital

Purpose: This study aimed to evaluate the implementation of solo surgery using a
laparoscopic scope holder in the single incision laparoscopic cholecystectomy (SILC).
Methods: With a glove port and a flexible high-definition scope, a SILC was performed
through the trans-umbilical single incisional site with CO2 pneumoperitoneum with the
pressure of 12 mmHg. Fifty nine cases of solo SILC using a scope holder (Solo-SILC) were
compared with 15 cases of cameraman-assisted SILC (Ca-SILC) in the aspect of surgical
outcomes.
Results: Two cases of chronic cholecystitis and 13 cases of GB stones in Ca-SILC, 20 cases
of cholecystitis including acute- and chronic-cholecystitis, gangrenous cholecystitis, 38
cases of GB stones and 1 case of GB polyp in Solo-SILC were included. One case in CaSILC (A) and 3 in Solo-SILC were emergency cases. Their mean BMI and operation time
were 23.0 3.6 kg/m2 & 64.4 16.6 min and 25.0 3.8 kg/m2 & 58.3 26.9 min in
Ca-SILC and Solo-SILC respectively (P = 0.077 and P = 0.416). The estimated blood loss
was scanty and there was no the additional assistant port in both groups. One case of
intraoperative gallbladder perforation and bile leak were happened in Ca-SILC and 3 cases
in Solo-SILC (P = 0.167). Postoperative outcomes including surgical complications, diet
restriction, diarrhea and hospital stay were not significantly different except shoulder pain
(P = 0.009).
Conclusions: Even with the limitations of the small series of patients, a Solo-SILC is
feasible. To confirm the safety of solo-SILC, further studies with a large sample size are
required.

Background: Laparoscopic liver resections for tumors located in postero-superior segments are more difficult than those for antero-lateral segments. Some tumors located on the
dome of the liver immediately beneath the diaphragm can be accessed easily from thoracic
cavity than from abdominal cavity because the distance from skin incision to the tumor is
much nearer thoracoscopically than laparoscopically. Here, we report our 4 cases of thoracoscopic transdiaphragmatic approach for postero-superior segments.
Methods: 4 patient underwent thoracoscopic transdiaphragmatic partial liver resection in
our hospital. All patients had hepatocellular carcinoma, 2 with chronic hepatitis C and 2
with Non Alcoholic Steato-Hepatitis (NASH). 2 patients had previous hepatectomy with
laparotomy. In all cases, tumors were located just beneath diaphragm in segment 8. Mean
tumor diameter was 3.0 cm (SD 0.2 cm) and mean resected liver volume was 16.3 g (SD
12.4 g).
Results: In all cases, patients were placed in the left lateral decubitus position with the right
arm suspended. Single-lung ventilation was initiated before trocar placement or first thoracotomy. Resection through mini-thracotomy with 3 thoracic port were done in all cases,
in one of which we needed to extend the thoracotomy scar because of severe intrathoracic
adhesion. Tumor location was confirmed via trans-diaphragmatic ultrasonography and
diaphragm was cut open directly above the tumor. Parenchymal transection was done using
Harmonic scarpel or clamp crushing method. Glissonean pedicules or venous branches were
secured and cut between clips and small bleedings were arrested with irrigation monopolar
cautery. Mean operative time was 280 min (SD 144 min) and mean blood loss was 343 g
(SD 233). In 3 cases, post-operative pleural effusion was complicated and 1 patients needed
extra drainage, while the other 2 treated with medication only. 1 patient had minor
superficial SSI. There was no mortality.
Conclusion: Thoracoscopic transdiaphragm approach seems to be safe and feasible for
tumors located in postero-superior segment immediately beneath the diaphragm. Postoperative pleural effusion seems the complication to watch for.

P386
P384
Laparoscopic Cholecystectomy in Cirrhotic Patients
Adrian Cotirlet, MD, PhD1, Marius Nedelcu, MD2, Laura Gavril,
MD3, 1Moinesti Emergency Hospital, 2Nouvel Hopital Civil, IRCAD,
Strasbourg, 3Iasi University Hospital
Introduction: Laparoscopic cholecystectomy is the gold standard treatment for the vast
majority of patients with symptomatic cholelithiasis. Although cirrhotic patients are twice
as likely to develop gallstones as compared with noncirrhotic patients, cirrhosis has historically been considered a relative, if not absolute, contraindication to laparoscopic
cholecystectomy. The aim of our study was to evaluate the results of laparoscopic cholecystectomies in cirrhotic patients.
Methods: The paper represents a retrospective study, which includes 104 patients (2.79 %)
with hepatic cirrhosis and symptomatic gallstones disease from our experience of 3726
laparoscopic cholecystectomies performed between January 2010 and December 2014. In
most of the cases 81 (77.8 %) cirrhosis was diagnosed preoperatively and it was classified
CHILD A - 53 cases and B-28 cases. Retrospective, suggestive for a chronic hepatic disease
were patient history (69 cases), transaminase elevations (47 cases), low platelet number (43
cases) and some ecographic findings (39 cases).
Results: There were 39 women and 65 men with mean age of 55 years (range 31- 79). The
cirrhosis was classified as macronodular in 68 cases (65.4 %), micronodular in 22 cases
(21.15 %) and mixt in 14 cases. Fourteen (13.46 %) of the patients were converted to an
open procedure, nine due to excessive hemorrhage from gallblader bed, three to an
immobile liver and two cases to impossibility of dissection. The mean operative time was
75 min (35105 min). Mean length of postoperative stay was 7.64 days (321). No reintervention was needed, but one patient necessitated blood transfusion. One case of mortality
was recorded.
Conclusion: The analysis of our results demonstrates the efficiency and the safety of
laparoscopic cholecystectomy in cirrhotic patients and permits us to sustain this method as
the first choice in treatment with symptomatic gallstones in cirrhotic patients.

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Strategies for Differentiating Xanthogranulomatous Cholecystitis

from Gall Bladder Carcinoma: A Tertiary Care Centre
Experience
Samiran Nundy, MCh, MA, FRCP, FRCS1, Kishore Rajaguru,
MBBSMSDNBMRCSEdFMASDMAS2, 1Sir Gangaram Hospitals
and Research Institute, New Delhi, India, 2Ng Teng Fong General
Hospital. Singapore
Aim: Xanthogranulomatous cholecystitis (XGC) mimics Gallbladder carcinoma (GBC) in
both preoperative and intra-operative setting and the patient may undergo an unnecessary
radical cholecystectomy rather than only a cholecystectomy which is associated with a
greater morbidity and mortality. We postulated that a pre-operative diagnosis of XGC might
benefit patients by avoiding radical procedures and attempted to identify the features of
XGC which differentiate it from GBC before and during surgery.
Methods: All the patients who underwent Gall bladder related operations (benign and
malignant), over a period of 5 years from 2010 to 2014 were reviewed in a tertiary centre
hospital in India. Out of these patients, histopathological reports of XGC were placed in a
Group A and GB malignancies were included in GROUP B. The following parameters are
recordedclinical features, biochemical, radiological findings including the presence of
gall stones/common bile duct (CBD) stones, focal or diffuse wall thickening of the GB, the
presence of intramural bands or nodules in the wall, lymph node enlargement, mucosal
enhancement, and the status of the interface between the liver bed and gall bladder and a
comparison was made between the groups.
Results: Patients with a long history of recurrent abdominal pain and who on imagingare
found to have a diffusely thickened gall bladder wall, with cholelithiasis, choledocholithiasis, and submucosal hypo attenuated nodules are likely to have XGC while those
with anorexia, weight loss, focal thickening of the gallbladder wall on imaging and dense
local organ infiltration are more likely to have GBC. The presence of lymph nodes on
imaging and the loss of a fat plane interface between the liver and gallbladder are not
differentiating factors. However the definitive diagnosis still remains a histopathological
examination to avoid radical resection in patients who have a benign condition.
Conclusion: The differentiation of XGC and GBC pre-operatively remains a challenge.
However the definitive diagnosis still remains a histopathological examination to avoid
radical resection in patients who have a benign condition.

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P387

P389

Laparoscopic Distal Pancreatectomy for Pancreatic Cancer is

Safe and Effective

10-Year Experience with Laparoscopic Pancreatic Surgery

by a Single Surgeon: A Challenge of Minimizing Postoperative
Pancreatic Fistula

Marita D Bauman, MD1, David C Becerra, MD2, E M Kilbane1,

Nicholas J Zyromski, MD1, C M Schmidt, MD1, Attila Nakeeb, MD1,
Michael G House, MD1, Eugene P Ceppa, MD1, 1Indiana University,
2
Walter Reed National Military Medical Center
Purpose: To compare the short-term and oncologic outcomes of patients with pancreatic ductal
adenocarcinoma (PDAC) undergoing laparoscopic distal pancreatectomy (LDP) and open distal
pancreatectomy (ODP).
Methods: Consecutive cases of distal pancreatectomy (n = 422) were reviewed at a single highvolume institution over a 7-year period (20082014). Inclusion criteria consisted of any patient
with PDAC by surgical pathology. Ninety-day outcomes were monitored through a prospectivelymaintained pancreatic resection database and the Social Security Death Index was used for 5-year
survival. Two-way statistical analyses were used to compare categories; variance was reported with
standard error of the mean; * indicates P value \ 0.05.
Results: Eighty-one patients underwent distal pancreatectomy for PDAC. Thirty-five underwent
LDP and 46 ODP. There were no statistical differences in demographics, BMI, and ASA classification. Intraoperative and surgical pathology variables were also comparable for LDP vs. ODP:
operative time (3.9 + 0.2 vs. 4.2 0.2 hours), duct size, gland texture, stump closure, tumor size
(3.2 0.3 cm vs. 4.0 0.4 cm), tumor stage (see table), and negative surgical margins (78 % vs.
87 %). Patients who underwent LDP experienced lower blood loss (310 68 ml vs. 597 95 ml;
p = 0.016*) and had fewer requiring transfusion (0 vs. 13; p = 0.0004*). Those who underwent
ODP had greater lymph node harvest (17.5 1.2 vs. 14.0 1.1; p = 0.03*), more positive lymph
nodes (1.6 0.29 vs. 0.77 0.24; p = 0.03*), and a higher incidence of type C fistula (0 % vs.
13 %; p = 0.03*). Post-operative outcomes are listed in the table. Median follow-up for all patients
was 11.4 months. Long-term oncologic outcomes revealed similar outcomes including distant or
local recurrence (28 % vs. 52 %; p = 0.05) and median survival (17.9 vs. 15.1 months), as well as
1-year (71 % vs. 59 %), 3-year (17 % vs. 13 %), and 5-year (9 % vs. 4 %) survival for LDP and
ODP respectively.
Conclusions: As one of the largest single institution series of LDP for PDAC, these results suggest
LDP as a safe surgical approach that is comparable from an oncologic standpoint to ODP for the
management of PDAC.

Takeyuki Misawa, MD, PhD, FACS1, Shuichi Fujioka, MD1, Ryota

Saito, MD1, Hiroaki Kitamura, MD1, Takeshi Gocho, MD2, Tadashi
Akiba, MD, FACS1, Katsuhiko Yanaga, MD, FACS2, 1Jikei
University Kashiwa Hospital, 2The Jikei University Hospital
Aims: To demonstrate our experiences, technical refinements, and clinical results of laparoscopic
pancreatectomy (LP) including distal pancreatectomy with splenectomy (DP), spleen-preserving
distal pancreatectomy (SpDP), enucleation, central pancreatectomy (CP), and single-incision
laparoscopic surgery (SILS).
Patients: From May 2005 to April 2015, we performed a total of 70 laparoscopic pancreatectomies
(DP in 36, SpDP in 26, enucleation in 6, CP in 2). Indications were benign/low-malignant lesions
including mucinous cystic neoplasm (MCN), neuroendocrine tumor (NET), intraductal papillary
mucinous neoplasm (IPMN), serous cystic neoplasm, solid and pseudopapillary tumor (SPT), nonneoplastic pancreatic cyst, and splenic diseases.
Methods: For standard multiport surgery, 45 trocars were used. In SILS, SILSTMPort was placed
in the umbilicus for articulating instruments and a 5-mm flexible scope. In all distal pancreatectomies, the pancreas was resected using a liner stapler. In enucleation for NET, harmonic scalpel
was employed for pancreatic resection. For splenic preservation, as the basic technique, both the
splenic artery and vein were isolated and preserved. For 2 patients with severe adhesion between
the splenic vessels and the pancreatic parenchyma, Warshaws technique was used. In 2 SILS (DP
and SpDP, respectively), technical refinements such as gastric suspension with stitches and splenic
hilum hanging maneuver with a cloth tape were applied.
Results: There was no conversion to open surgery. The mean operation time, blood loss, and
postoperative hospital stay were 272 94 min, 69 138 mL, and 11 9.1 days, respectively.
Only 5 (7.1 %) patients developed clinically significant pancreatic fistula (grade B: 4, C: 1). In
comparison between DP and SpDP, there was no statistical difference in blood loss, operation time,
postoperative hospital stay, preoperative platelet count, and tumor size. However, postoperative
platelet count was significantly higher in DP (37 1.7 vs. 22 4.5 9 104/ll, p \ 0.0001).
Postoperative pathological study revealed that two patients with preoperative diagnoses of IPMN
and one with MCN had non-invasive carcinoma. Another patient with SPT was also found to have
limited micro-invasive lesion within the pancreatic parenchyma, thus diagnosed as carcinoma.
These three patients are now under close observation.
Conclusions: LP is a safe and optimal procedure for benign/low-malignant lesion in the pancreas.
Especially, SpDP should be recommended in terms of the preventing postoperative thrombocytosis.

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P388
Laparoscopic Biliodigestive Reconstruction: One Year
Experience in a Single Institution
Daniel Gomez, MD, Pedro Villadiego, MD, Daniel Perez, MD,
Manuel Sanchez, MD, CPO
Introduction: Biliary tract disease involve a broad spectrum of pathologies, from bening to
malignant conditions that not always can be manage by endoscopy.
Biliodigestive diversions are still performed by laparotomy in a large number of cases due to the
technical challenges of this type of anastomosis in the laparoscopic aproach.
Methods: We performed 24 consecutives laparoscopic biliodigestive diversions in a single institution (January 2014 - February 2015) by using two techniques including choledochojejustomy
+ Roux and Y Witherspoon a simplified techniques and choledochoduodenostomy.
Records were reviewed for demographic data, mean operative time, blood loss and intra and
postoperative complications.
Results: 24 patients were performed 19 females, 5 males 18 choledochoduodenostomies, 5
choledochojejunostomies and Rouxen-Y
All procedures were carried out succesfully
Mean operative time: 138.6 minutes
Blood loss was less than 15 cc
No conversions
We registered no major complications or re-interventions
Conclusion: The safety and efficacy of laparoscopic biliodigestive diversion was proven in this
case series. The procedure can be performed within an acceptable time frame by trained surgeons in
advanced laparoscopic techniques.

Robotic Assisted Completion Cholecystectomy: The Utility

of a Robot in a Difficult Operation
Imran Siddiqui, MD, FACS, Russell Kirks, MD, Erin Baker, MD,
Allyson Cochran, MSPH, Ryan Swan, MD, David Iannitt, MD,
Dionisios Vrochides, MD, John Martinie, MD, Carolinas Medical
Center
Background: We retrospectively analyzed six cases of robotic-assisted completion cholecystectomy to evaluate the safety and efficacy of the robotic platform for this treatment indication. Partial
cholecystectomy may be performed in the setting of gangrenous cholecystitis when inflammation
obscures visualization of critical structures. As a result, the gallbladder is transected at the
infundibulum or distal body without attempting dissection of the triangle of Calot to prevent bile
duct injury. Leaving a remnant gallbladder can result in symptomatic retained stones, biliary
fistulae, and abscesses requiring surgical intervention. Reoperation is also required for incidental
gall bladder carcinoma. The robotic platform offers improved visualization and dexterity in settings
of complex anatomy. We describe an early safety and feasibility case series of robotic-assisted
completion cholecystectomy.
Methods: Patients undergoing robotic completion cholecystectomy from 2010 to 2015 at a quaternary HPB referral center were identified. Patient demographics, prior surgical and endoscopic
interventions, intraoperative findings, and postoperative complications were analyzed retrospectively. 90-day morbidity and mortality, reoperation, hospital length of stay, and readmission were
tracked.
Results: Six patients were identified and included in this review. All six were initially found to
have gangrenous cholecystitis and received subtotal cholecystectomy (3 laparoscopic, 2 open, 1
laparoscopic to open conversion). After initial surgery, two patients presented with a symptomatic
gallbladder remnant, one developed biliary fistula, and three patients (50 %) had incidental diagnosis of adenocarcinoma of the gallbladder (two with T2 disease and one tumor in situ). All
procedures were completed robotically. Median age was 59.5 years (range 4265 y), median BMI
was 30.9 (range 2333.25), and the American Society of Anesthesiologists (ASA) classification
was 3 in all patients. Median EBL was 72.5 mL (range 50150 mL) while median operative time
was 181.5 min (range 176206 min). The operative times for two patients could not be located,
excluding them from analysis of this variable. All gallbladder malignancies were staged with portal
lymphadenectomy at the time of completion cholecystectomy. No immediate complications or bile
leaks occurred and no postoperative intervention was required. Median hospital length of stay was
2 days (range 14 d). At median follow-up of 22 months, all patients were free of symptoms and
port site recurrence.
Conclusion: This early case series supports the safety and feasibility of completion cholecystectomy performed with the surgical robot. Further studies are needed to identify if the robotic
approach can be extended to all patients in this cohort.

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P393

The Utility of Vessel Tracking Technique Using Doppler

Ultrasonography for Laparoscopic Surgery in Biliary Tract
and Pancreas

Laparoscopic Resection and Marsupialization of Complex

Hepatic Cyst

Kosei Maemura, Yuko Mataki, Hiroshi Kurahara, Yota Kawasaki,

Koji Minami, Satoshi Iino, Masahiko Sakoda, Shinichirou Mori,
Shinichi Ueno, Hiroyuki Shinchi, Shoji Natsugoe, Kagoshima
University Graduate School of Medical and Dental Sciences
Background: Doppler ultrasonographic imaging provides visualization of vessels in the body. Doppler flow meter makes possible to detect invisible
vessels buried in the tissue. As these techniques are non-invasive and easy to perform during the surgery, we have introduced these techniques in
laparoscopic surgery in order to reduce operative unexpected vessel injury. We evaluated the utility of the intraoperative Doppler ultrasonography
guided vessel detection and tracking technique (Dop-US) for laparoscopic surgery in biliary tract and pancreas.
Patients and Methods: Consecutive 20 patients who received laparoscopic cholecystectomy (LC) and 10 patients who received laparoscopic distal
pancreatectomy (Lap-DP) were introduced Dop-US method and investigated. The Dop-US was performed using the bidirectional Doppler flow
meter laparoscopic probe for searching vessels during operation. We identified the right hepatic artery (RHA) and cystic artery (CA) in LC, common
hepatic artery (CHA) and splenic artery (SA) in Lap-DP by measuring flow speed and wave shape pattern. The detection rate of each artery was
compared with Dop-US and preoperative enhanced CT with three-dimensional image.
Results: The wave form pattern of RHA and CA acquired by Dop-US differed clearly. The average of maximum flow speed was 30.3 cm/sec in
RHA and 8.1 cm/sec in CA with statistical significant difference (p \ 0.001). Dop-US identified RHA in all cases. The detection rate of CA was
60 % (12/20) in CT and 90 % (18/20) in Dop-US. Dop-US achieved complete detection of CHA and SA in all patients of Lap-DP without any
pancreas parenchyma injury.
Conclusions: It was quite simple and easy to perform vessel detection technique using Doppler US in LC and Lap-DP. This approach was suggested
to be the contributing procedure for improvement in safety of laparoscopic surgery in biliary tract and pancreas.

William D Stembridge, DO1, Rahul Sharma, DO1, Ely Sebastian,

MD2, 1Rowan SOM, 2Our Lady of Lourdes Medical Center
Objective of Study: A case report was designed to demonstrate the effective resection of a large, complex, infected hepatic cyst with insidious
presentation in a medically fragile 78-year-old female. Laboratory values, computed tomography images and intraoperative photographs are used to
demonstrate the case and surgical techniques use to successfully treat the patient.
Methods and Procedures: A 78-year-old female presented to the emergency department complaining of epigastric pain for twenty-four hours
accompanied by fevers, chills and rigors. She was found to be septic secondary to a 13.8 9 12.6 9 12.9 cm complex collection in the left lobe of the
liver. Percutaneous drainage by interventional radiology was avoided due to concerns for hydatid cyst. After adequate resuscitation and broadspectrum antibiotic coverage, the patient was taken to the operating room. Diagnostic laparoscopy was performed using one 12 mm and two 5 mm
trocars. Brown-colored purulent fluid was found in all quadrants of the abdomen and cultures were taken. Enseal energy device was used to take
down the falciform ligament and the omental adhesions covering of the left lobe of the liver. At this time the liver cyst was perforated and a copious
collection of brown fluid was encountered and suctioned. The Enseal was used to perform a hepatotomy into the abscess cavity and the area was
washed out copiously. The free wall of the cyst was resected with Enseal leaving the remaining portion marsupialized to the omentum[Images
included depicting the large complex cyst extending from the left lobe of the liver]. Argon beam coagulation was applied to the left lobe of the liver
until hemostasis was obtained [Multiple Images depicting resection, cyst, hemostatis]. The abdomen was again washed copiously and two 19 French
Blake drains were placed; one was directed into the cyst cavity with the second in Morrisons pouch. The 12 mm trocar site was closed in two layers.
The patient recovered well with steadily improving white blood cell counts, liver function tests. Drain quality and quantity improved and drains were
removed one at a time. Pathology was negative for malignancy and cultures grew multiple enteric organisms. The patient was discharged home after
completing an antibiotic course.
Conclusion: Large hepatic resections are traditionally relegated to open operations. New techniques and devices have made laparoscopic resection
of hepatic an effective and safe procedure for patients who have no contraindications.

P392
Retrospective Analysis of the Factors Affecting the Risk
and Difficulty of the Laparoscopic Surgery for Acute Cholecystitis
Koetsu Inoue1, Tatsuya Ueno1, Orie Suzuki1, Masanobu Hayashi1,
Kentarou Shima1, Ryouichi Anzai1, Shinji Gotou1, Michinaga
Takahashi1, Takanori Morikawa2, Takeshi Naitoh2, Hiroo Naitoh1,
1
South Miyagi Medical Center, Department of Surgery, 2Tohoku
University Graduate School of Medicine, Department of Surgery
Introduction: According to the Tokyo guidelines, cholecystitis is classified into three categories (Grade I, II, III) depending on its severity. The
guideline recommends some therapeutic options for each categories. The guideline notes early laparoscopic cholecystectomy (LC) or gallbladder
drainage (PTGBD) is required for grade II cholecystitis. The aim of this study is to evaluate the risk factors for the difficulty of the LC in the Grade II
cholecystitis.
Patients and Methods: Medical records since 2010 to 2015, were retrospectively reviewed. A total of 98 Grade II cholecystitis patients who
underwent LC were enrolled in this study, including patients converted to open surgery. The patients were divided into two groups: difficult LC
group and non-difficult group. The difficult LC was defined as 1. Operation time [180 minutes and/or 2. Blood loss [300 ml. Preoperative
characteristics and postoperative outcomes were analyzed. Comparisons of paired data were analyzed by two-tailed Students t test and/or Pearsons
chi-square test. Statistical analyses were performed using JMP Pro 11 software (SAS Institute).
Results: A univariate analysis revealed the duration of symptoms was a risk factor of the difficulty (difficult LC group vs non-difficult LC group,
64.0 vs 31.3 hrs). The incidence of postoperative complications was significantly higher in a difficult LC group compared with non-difficult LC
group (25.0 vs 6.8 %). Postoperative hospital stay was also significantly longer in the non-difficult group (9.0 vs 6.0 days). When looking at relation
between postoperative complications and the duration of symptoms, cut off value of the duration of symptoms was 96 hrs according to ROC curve.
Incidences of postoperative complications in patients who received the treatment within 96hrs and over 96hrs, were 8.0 % and 40.0 %, respectively.
Conclusion: In the patients who have longer duration from its onset, laparoscopic surgery for acute cholecystitis would be difficult and would have
the higher risk of complications.

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P394
Gender-Associated Differences in Gallbladder Pathology
and Disease Severity
Sean M Wrenn, MD, Wasef Abu-Jaish, MD, FACS, University
of Vermont Medical Center
Introduction: Cholecystectomy is a commonly performed surgical procedure in the United States, with the most common indications including
symptomatic cholelithiasis and cholecystitis. Previous data have suggested that male patients undergoing cholecystectomy have longer operative
times and higher complication rates, although the reason for the phenomenon is unknown.
Methods: We performed a large single-center retrospective analysis of all gallbladder specimens sent for analysis to the department of Pathology
between 20092014. Exclusion criteria included preoperative suspicion for malignancy or polyp, and non-biliary indications for gallbladder
resection (such as trauma). The pathological results were tabulated, including both common and rare findings. The results were then stratified to
determine differences between gender, and chi squared analysis was performed to determine statistical significance between groups.
Results: A total of 2,153 pathology specimens were reviewed, and after exclusion criteria, 1,984 specimens were included for analysis in the study.
We noted statistical significant differences between the male and female groups in markers commonly associated with disease severity. Male
patients gallbladder specimens were more likely to have noted acute cholecystitis (32.5 vs. 15.2 %, p \ .001), gangrene or ischemia (9.9 vs. 2.2 %,
p \ 0.001), and serositis (2.4 vs. 0.9 %, p \ 0.01). In contrast, females were more likely to have cholesterolosis (21 vs. 10 %, p \ 0.001), chronic
cholecystitis (90.5 vs. 85.1 %, p \ 0.001), and mild cholecystitis (10.1 vs. 6.6 %, p \ 0.01).
Conclusions: Male gallbladder specimens were significantly more likely to have several histopathological markers of severe and acute inflammation,
such as gangrene, ulceration, and serositis. In contrast, females more commonly had noted cholesterolosis of the gallbladder and were more likely to
have chronic and mild cholecystitis as noted by the interpreting pathologist. The more advanced disease noted on male gallbladder specimens may
account for higher levels of complications seen with male patients who undergo cholecystectomy, however further study is needed to better elucidate
these findings.

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P397

What is the Best Practice Management for Patients with Acute

Cholecystitis?

Outcome of Pure Laparoscopic Hepatectomy for Hepatocellular

Carcinoma in Patient with Cirrhosis and Thrombocytopenia

Koji Asai, MD, Manabu Watanabe, Hiroshi Matsukiyo, Tomoaki

Saito, Tomotaka Ishii, Ryohei Watanabe, Toshiyuki Enomoto,
Natsuya Katada, Yoshihisa Saida, Shinya Kusachi, Department
of Surgery, Toho University Ohashi Medical Center

Tan To Cheung, MS, The University of Hong Kong Queen Mary

Hospital

Introduction: We assessed the best practice management for patients with acute cholecystitis (AC) according to our own experience.
Patients and Methods: We analyzed 273 patients who underwent surgery at our
department.
Results: Impact of revised guidelines (Tokyo Guidelines 2007; TG07)
The therapeutic resulted obtained before and after the publication of TG07 were analyzed.
Preoperative gallbladder drainage did not significantly differ; however, percutaneous
transhepatic gallbladder aspiration was performed significantly more often than percutaneous transhepatic gallbladder drainage after the publication of TG07. The rate of
performance early laparoscopic cholecystectomy (ELC) also significantly increased, rising
from 28.2 % to 83.7 % and 42.5 % to 75 % in patients with mild and moderate AC,
respectively. The rate of conversion to open surgery significantly decreased from 28.1 % to
9.1 % in patients with moderate AC. The rate of postoperative complications did not
significantly differ. In addition, the duration of hospital stay was significantly shouter in
both mild and moderate AC after the publication of the guidelines.
Risk Factor of Conversion to the Open Surgery: The rate of conversion to open surgery
was 12.9 %, including 6.7 % in mild AC and 18.5 % in moderate AC. A duration of[72 h
from symptom onset and a high C-reactive protein value were significant risk factor of
conversion to the open surgery.
Analysis of Data on Elderly Patients: We analyzed the data on patents between the age of
\74 years and C75 years. When comparing data on ELC and delayed laparoscopic
cholecystectomy, we did not find a significant difference in the rate of conversion to open
surgery and postoperative complication. The duration of hospital stay showed significant
shorter in elderly ELC group.
Timing of Surgery: We divided timing of surgery relative to the onset of symptoms into
four groups, including A (\3 days), B (47 days), C (821 days), and D ([22 days). The
operative time and the duration of hospital stay were significantly shorter in group A;
however, the rate of conversion to open surgery did not significantly differ across the four
groups.
Conclusion: Early laparoscopic cholecystectomy was identified as the best practice management for all AC patients.

Introduction: Bleeding in the presence of thrombocytopenia has been a major issue in liver
resection even in open procedures. Although laparoscopic liver resection has been reported
to be a safe and effective treatment even in patients with liver cirrhosis, there is very little
evidence on patients with thrombocytopenia.
Method: Between October 2002 and September 2015, 131 patients had undergone curative
pure laparoscopic liver resection for solitary hepatocellular carcinoma (HCC). Thrombocytopenia was define as platelet counts \100 9 109/L. Amongst 131, patients received
laparoscopic liver resection, 16 patients had platelet count \100 9 109/L (Group 1).
Another 116 patients with platelet count equal or more than 100 9 109/L (Group 2). The
immediate operation outcome and survival including operation morbidity, were compared.
The disease free survival and median survival were also compared.
Results: Comparing Group 1 to Group 2, the median operation time was 184 minutes vs
175 minutes p = 0.582, the median blood loss was 200 ml vs 100 ml (P = 0.189). 1 patient
(6.3 %) from Group 1 had blood transfusion and 3 patients (2.9 %) from Group 2 had blood
transfusion. (p = 1) The hospital stay was 4 days vs 4 days (P = 0.984), postoperative
complication was 3 (18.8 %) vs 8(7.8 %) (p = 0.351), There was no hospital mortality in
both groups of patients. The overall median survival was [114.1 months vs 136.1 months
(P = 0.289).
Conclusion: Pure laparoscopic liver resection is a safe treatment option for HCC. Good
outcome is observed in patients even with low platelet count.

P398
P396
Effect of Enteral Glutamine in the Outcome of Severe Acute
Pancreatitis a Randomised Controlled Trial
Saheer Neduvanchery, MBBS, MS, Vikas Gupta, MBBS, MS, McH,
Td Yadav, Rakesh Kocherr, PGIMER, CHANDIGARH
Objective: To determine the effect of enteral glutamine in the outcome of SAP.
Methods: 62 patients (35 males) with mean age 42.11 13.44 years with SAP were
randomised into study group (32 patients) who received enteral glutamine for two weeks
and control group (30 patients). The 2 groups were followed till discharge/death. Biochemical, hematological parameters and serum albumin, were measured on day 0, 7, 14 and
28 and CRP on day 0, 7, and 14. Clinical outcome was compared between 2 groups.
Results: Gall stone was the commonest etiology (41.90 %) followed by alcohol (30.60 %).
The mean duration of onset of disease to hospital admission was 4.79 4.05 days (range
123 days). All demographic parameters, severity indices ie BISAP score (2.28 1.023 vs
2.03 .928), APACHE II at admission (10.09 4.672 vs 9.81 4.718) and mCTSI
(7.44 2.169 vs 7.20 2.325), and serum CRP were comparable between two group.
28 day serum albumin and APACHE II score were better in study group vs control group
(3.386 0. 505 vs 2.721 0.734, p = 0.025 and 6.25 3.076 vs 10.00 3.559,
p = 0.07 respectively). Incidence of organ failure, local/infectious complications, need for
interventions, duration of hospital and ICU stay and mortality were similar.
Conclusions: Enteral glutamine showed improvement in serum albumin and trend towards
decreasing the severity of severe acute pancreatitis during the course of illness. However it
did not translate into reduction in infectious complication, organ failure, need for invasive
intervention, duration of hospital and ICU stay and mortality.

Fluorescent Cholangiography in Laparoscopic Cholecystectomy:

The Initial Canadian Experience
Greg Bodie, MD, FRCSC, Geoffrey Chow, MD, Jack Chiu, MD,
FRCSC, Mark Meloche, MD, FRCSC, Garth Warnock, MD, MSc,
FRCSC, Adam Meneghetti, MD, MHSc, FRCSC, Neely Panton,
MBBS, FRCSC, FACS, University of British Columbia
Introduction: Laparoscopic cholecystectomy is the most commonly performed general
surgical procedure worldwide. Bile duct injury rates have not decreased despite increased
experience and training with this procedure. Laparoscopic fluorescent cholangiography
using Indocyanine Green (ICG) for real-time intraoperative near infrared (NIR) imaging of
the extrahepatic biliary system has potential to help identify anatomy and may possibly
decrease rates of inadvertent biliary injury. Here we present the initial Canadian experience
with this technique.
Method: An objective analysis of NIR imaging during elective cholecystectomy in Canada
was performed. Patient demographics, intraoperative details, and subjective surgeon data
were recorded. The primary endpoint was to identify real-time rates of cystic and common
bile duct identification. Survey questions were obtained regarding the functionality, use,
and perceived benefit of the technology.
Results: NIR imaging with ICG cholangiography was used in 21 initial cases. Patient
characteristics showed an average age of 52, BMI of 30, ASA class 2. The average operative time with 79 +/- 31 minutes. The cystic duct, CBD, and CHD were visualized with
NIR in 86 %, 67 %, and 38 % of cases respectively. Use of fluorescent cholangiography
incorporated smoothly into the operation in 83 % of cases, and facilitated identification of
anatomy in a majority of cases. There were no adverse reactions or complications related to
the technology.
Conclusions: Fluorescent cholangiography allows for non-invasive real time visualization
of the extra-hepatic biliary tree. This technology has not increased operative times and
facilitates obtaining a critical view of safety. This technology has received positive feedback in this initial Canadian use and may be a durable adjunct for laparoscopic surgery.

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P401

Modified Lasso Technique for Laparoscopic Distal

Pancreatectomy

Is the Risk of Operating on Acute Cholecystitis Too Great?

A Comparison of National Outcomes Following Laparoscopic
Cholecystectomy

Hiroshi Kurahara, Kosei Maemura, Yuko Mataki, Masahiko Sakoda,

Satoshi Iino, Yota Kawasaki, Koji Minami, Shinichi Ueno, Hiroyuki
Shinchi, Shoji Natsugoe, Kagoshima University
Introduction: Distal pancreatectomy (DP) is a standard procedure for the treatment of malignant, premalignant, and
certain benign lesions arising from the pancreatic body and tail. Laparoscopic DP has become popular in the past
several years.
One of the difficulties with this approach is ligating the splenic artery and vein before transection of the pancreas. The
purpose of this study was to examine the usefulness of the modified lasso technique for laparoscopic DP.
Methods and Procedures: We reviewed the medical records of 56 patients who underwent DP with laparotomy
(laparotomy group, n = 27), conventional laparoscopic surgery (conventional group, n = 26), and modified lasso
technic (lasso group, n = 3). Patients with pancreatic cancer were excluded from this comparative study because they
need radical resection with lymph node dissection. In the DP with laparotomy and conventional laparoscopic DP,
splenic artery and vein were ligated before transection of the pancreas. In the modified lasso technique, splenic artery
was clipped near the root. Thereafter, the body of the pancreas with the splenic artery and vein was retracted away
from the retroperitoneum and transected using the stapler without ligation of the splenic artery and vein. We compared
the clinical data between the 3 patient groups.
Results: The mean operating time and amount of bleeding in the lasso group was 237 min and 10 ml, respectively.
The operating time in the lasso group was significantly shorter than that in the conventional group (P = 0.002). The
amount of bleeding in the lasso group was significantly less than that in the laparotomy group (P = 0.015), but there
were no significant difference between the conventional group and the lasso group. There was no significant difference
of postoperative complication including pancreatic fistula (PF) between the 3 groups. No patients in the lasso group
experienced grade B or C PF after surgery.
Conclusions: The modified lasso technique for laparoscopic DP is useful to reduce the operating time without
increasing the incidence of postoperative complication.

Emily Benham, Samuel W Ross, MD, MPH, Ciara R Huntington,

MD, Peter E Fischer, MD, MS, John M Green, MD, Bradley W
Thomas, MD, B. Todd Heniford, MD, A. Britton Christmas, MD,
Ronald F Sing, DO, Carolinas Medical Center
Introduction: Many HPB experts and the Tokyo guidelines recommend delaying cholecystectomy for advanced acute
cholecystitis, given an increased risk of complications, and operating when in a chronic phase. Therefore, our goal was
to use national data to examine risk of post-operative complications following laparoscopic cholecystectomy (LC) for
acute vs. chronic cholecystitis.
Methods and Procedures: The ACS NSQIP database was queried for all LC from 20052013. Two cohorts were
defined by diagnosis codes acute cholecystitis (AC) chronic cholecystitis (CC). Univariate tests were used to compare
the cohorts. Multivariate analysis was performed for outcomes controlling for age, BMI, gender, diabetes, smoking,
and Charlson Comorbidity Index. Conversion rate and common bile duct injury are not tracked in NSQIP.
Results: There were 145,644,520 LC: 44,436 with IOC and 1,168 with common bile duct exploration. LC was
performed for AC in 46,189 cases and 99,455 for CC. Complication rates were low: wound complication 0.77 %,
intra-abdominal abscess 0.45 %, reoperation 0.94 %, readmission 4.40 %, and 30 day mortality 0.23 %. The AC
cohort had older, more male, higher BMI, more inpatient, diabetics, and higher CCI; p \ 0.001 for all. Univariate
outcomes are reported in the Table 1, and all complications, except for superficial SSI, and mortality were higher in
the AC cohort. On multivariate analysis, LC for AC had an increased odds of reoperation (OR, CI: 1.36, 1.161.60),
readmission (1.33, 1.231.43), intra-abdominal abscess (2.19, 1.872.56), and 30 day mortality (1.78, 1.422.22)
when compared to LC for CC.
Conclusions: Rates of 30 day complications are low for laparoscopic cholecystectomy, but, they are slightly increased when performed for acute
compared to chronic cholecystitis. Surgeons and patients should balance these minimally increased risks with the cost, discomfort, and healthcare
resources associated with delaying cholecystectomy.

Table 1

Laproscopic choliecystectomy for cholecystitis postoperative outcomes by acuity

P400
En-Bloc Stapling Transection of Glissonian Pedicles and LHV
for Laparoscopic Left Lateral Sectionectomy
Takashi Kaizu, MD, Yusuke Kumamoto, MD, Hiroshi Tajima, MD,
Ryo Nishiyama, MD, Hiroshi Kawamata, MD, Masahiko Watanabe,
MD, Department of Surgery, Kitasato University School of Medicine
INTRODUCTION: Laparoscopic left lateral sectionectomy (LLLS) is one of the widely accepted procedures for
laparoscopic liver resection (LLR). In general, LLLS requires two-step stapling transection. One is for Glissonian
pedicles to Segment II/III, the other is for left hepatic vein (LHV). Here, we report the new technique of en-bloc
stapling, transect both Glissonian pedicles and LHV simultaneously.
Methods: Between December 2002 and September 2015, 193 LLR were performed and 38 LLLS (20 % of 193 LLR)
were included in this retrospective study. Among the 38 LLLS, we applied two-step stapling technique in 35 cases
(two-step group) and en bloc stapling technique in recent 3 cases (en-bloc group), and evaluated surgical outcomes.
Surgical Technique: The falciform and left triangular ligament was divided using a harmonic scalpel. After liver
parenchymal transection using CUSA Exel, Segment II/III pedicles were stapled and divided using Echelon FlexTM 60
Blue cartridge. Residual parenchyma including LHV was stapled and divided using Echelon FlexTM 60 White
cartridge. In the en-bloc stapling technique, both Glissonian pedicles and LHV were stapled and divided simultaneously using Echelon FlexTM 60 Blue cartridge. The cotton tape was used for countertraction of Segment II/III,
which prevent liver tissue extrusion and slippage during stapler closure.
Results: There was no significant difference in surgical outcomes between two-step group and en-bloc group as
follows; the median operative time, intraoperative blood loss, and postoperative hospital stay were 220 versus 315
minutes (two-step group versus en-bloc group, P = 0.18), 100 versus 100 ml (P = 0.15), and 9 versus 7 days
(P = 0.06), respectively. In two-step group, there were 3 (9 %) conversions to laparotomy and 4 (11 %) postoperative
complications. No complication and open conversion occurred in en-bloc group. There was no mortality in both
groups.
Conclusions: Sufficient exposure of the glissonian pedicles and LHV for safety stapler positioning may require longer
operative time in en-bloc group. LLLS using en-bloc stapling transection is simple, safe and feasible technique with
acceptable morbidity.

P402
Laparoscopic Fenestration of Liver Cyst Using IndocyanineGreen Fluorescent Cholangiography
Koji Minami, Masahiko Sakoda, Satoshi Iino, Kiyokazu Hiwatashi,
Kosei Maemura, Yuko Mataki, Hiroshi Kurahara, Yota Kawasaki,
Shinichiro Mori, Hiroyuki Shinchi, Shinichi Ueno, Shoji Natsugoe,
Kagoshima University
Liver cyst is benign disease, but it is needed a surgical treatment when there are symptoms such as the abdominal
distension. Laparoscopic fenestration is useful surgical treatment of this disease, but bile duct injury is one of the
intraoperative complications that should be careful. In addition, there are some case that bile duct could not be
detected because of compression by the huge or multiple liver cyst. We report the case of a polycystic disease of liver
for which we performed laparoscopic fenestration using intraoperative fluorescent cholangiography with indocyaninegreen.
Case: In July 2004, a 45-year-old woman was pointed out multiple cyst of liver by follow-up during pregnancy, and
was diagnosed as polycystic disease by close examination. She was followed up regularly. In March 2014, She was
consulted our department for surgical treatment, because of abdominal distension. We planned Operation.
Operation Method: ICG (2.5 mg/body) was infused one hour before surgery. We added small skin incision to the
naval direct top. We did fenestration directly to make space. We shifted to laparoscopic surgery by using EZ Access
system. We could detected bile duct by using ICG-Fluorescent laparoscopy during operation. It was useful to detect
the narrowed bile duct and, we could carried out fenestration safely.
Discussion and Conclusion: Laparoscopic fenestration is useful treatment of liver cyst, but bile duct injury is one of
the complication which should be careful. To detect the bile duct, we make preoperative examination routinely such as
MRCP or DIC-CT. But there are some cases that the biliary duct could not be detected because of compression by the
huge or multiple cyst. In present case, it was useful to detect bile duct during operation by using intraoperative ICGfluorescent cholangiography. Fluorescent cholangiography using indocyanine-green is effective procedure to detect
bile duct during laparoscopic fenestration

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S429

P403

P405

Laparoscopic Hepatectomy Using a Monopolar Soft-Coagulation

Device While Controlling Intraoperative Bleeding
to the Maximum

Re-do Laparoscopic Pancreaticoduodenectomy After

Laparoscopic Pancreatic Surgery

Mitsuo Miyazawa, MD, Masayasu Aikawa, MD, Katsuya Okada,

MD, Yukihiro Watanabe, Kojun Okamoto, Isamu Koyama, MD,
Saitama Medical University International Medical Center
Among intraoperative complications of total laparoscopic hepatectomy (TLH), venous
hemorrhage is the most frequent and difficult-to-treat complication. We use a monopolar
soft-coagulation devices for not only hemostasis, but also detachment of blood vessels. The
aim of this prospective, nonrandomized study was to investigate the potential contribution
of a monopolar soft-coagulation device to the limitation of intraoperative blood loss in
patients undergoing TLH.
Methods: From January 2008 to May 2015 at our department, TLH was performed in 180
cases, including 160 cases of partial hepatectomy and 5 cases of lateral sectionectomy of
the left hepatic lobe. We keep the following points in mind for the procedure of partial
hepatectomy using a monopolar soft-coagulation device for hepatocellular carcinoma. 1)
Even in case of a small amount of bleeding, hemostasis is immediately performed before
moving to the next site of transection. 2) For detachment of the vein, a monopolar softcoagulation device is pressed on the resection surface of the liver to destroy hepatocytes. 3)
Regarding the area around the hepatic vein, holes from which the branches of the hepatic
vein fall out are identified with a monopolar soft-coagulation device (while dripping water)
and closed.
Results: The blood loss was 82.6 (0500) ml. The operative time was 207 (127468)
minutes. The duration of hospital stay after surgery was 7.6 (321) days. Postoperative
complications occurred in 8 cases (intraabdominal abscess:3, wound infection:2, intraabdominal hemorrhage:1, bile duct stricture [stricture of B2 and B3 after resection of a tumor
in S4]:1, and umbilical hernia:1). The peak aspartate aminotransferase (AST) level was 320
(571964) IU/L. Although there were cases showing high AST levels, no sign of hepatic
failure was observed during the perioperative period in any case.
Conclusion and Discussion: The use of a monopolar soft-coagulation device in laparoscopic hepatectomy improves surgical results with minimal blood loss and low rate
morbidity.

Wei-Wei Jin, MD1, Chao Lu1, Yi-Ping Mou, MD, FACS2, Rong-Gao
Cheng1, Jing-Rui Wang1, Xiao-Wu Xu2, 2Division
of Gastroentropancreas, Department of General Surgery, Zhejiang
Provincial Peoples Hospital, 1Medical School, Zhejiang University
Background: Laparoscopic pancreatectomy has been gaining acceptance widely with clear
mini-invasive advantages. Re-do laparoscopic pancreaticoduodenectomy after laparoscopic
pancreatic surgery is a very difficult procedure. The aim of this study is to present the
feasibility and safety of re-do laparoscopic pancreaticoduodenectomy after laparoscopic
pancreatic surgery.
Methods: From September 2013 to December 2014, there were 3 cases undergoing pure
laparoscopic pancreaticoduodenectomy with 5 ports. Of these three patients, a 74-year old
male underwent laparoscopic distal pancreatectomy as a diagnosis of pancreatic adenocarcinoma and CT showed a low-density mass in the pancreatic head that considered as
pancreatic adenocarcinoma 3 years later. Another 49-year old male underwent laparoscopic
pancreatic enucleation for pancreatic neuroendocrine tumor with lymph node metastasis at
pancreatic head in 3 months ago. The last one was 45-year old male undergoing laparoscopic pancreatic enucleation for multiple gastrinoma at pancreatic head and surgical
exclusion of splenic artery aneurysms without splenectomy, but the symptom did not disappear and MRI revealed multi-mass at pancreatic head.
Results: The mean operation time was 366.67 minutes (range, 310400 min), and the blood
loss was 183.3 ml (range, 150200 ml). There were no postoperative complications and the
mean postoperative hospital stay was 16 days (range, 1320 days). Diagnosis was pancreatic adenocarcinoma, pancreatic neuroendocrine tumor and gastrinoma. The mean
follow-up was 15 months, and the patients with total pancreatectomy suffered diabetes that
was well controlled by insulin.
Conclusion: Re-do laparoscopic pancreaticoduodenectomy after laparoscopic pancreatic
surgery is feasible and safety in skilled surgeons at selected patients.

P406
P404
Laparoscopic Liver Resection for Cystic Lesions: a 20-Year
Experience
Elie K Chouillard1, Chady Salloum, MD2, Yves Lopez, MD1, Andrew
Gumbs, MD1, Daniel Azoulay, MD2, 1PARIS POISSY MEDICAL
CENTER, 2HENRI MONDOR HOSPITAL
Introduction: In France, the vast majority of liver cystic lesions are either simple liver
cysts (SC) or hydatid cysts (HC). If symptomatic, SC is best treated by laparoscopic
unroofing. A HC is treated by simple cystectomy or pericystectomy. The aim of this study
was to review the management strategy in patients who presented with atypical cysts. The
results of laparoscopic approach to such patients were analysed.
Methods and Procedures: This is a retrospective review of patients who had liver
resection for cystic lesions between January 1, 1995, and December 31, 2014. Management
strategies were detailed, including clinical, biological, and imaging features. Operative
morbidity and mortality as well as long-term outcome were also assessed. A comparison
between preoperative and postoperative diagnoses was performed.
Results: Forty-nine patients (33 women and 16 men) underwent 59 liver resections,
including 20 left lateral resections, 15 right hemi-hepatectomies, 12 left hemi-hepatectomies and 12 segmentectomies or wedge resections. Thirty-four patients (69.4 %) had 37
laparoscopic procedures and were the subjects of this study. The final diagnosis included
HC in 12 patients (35.3 %), cystadenoma in 7 (20.6 %), SC in 4 (11.8 %), Carolis disease
in 4 (11.8 %), cystadenocarcinoma in 2 (5.9 %) and miscellaneous in the 5 remaining
(14.6 %). There was no mortality and the postoperative morbidity rate was 16.2 %. Longterm follow-up revealed that, besides patients with malignancies whose outcome was
dismal, overall prognosis was positive with efficacious symptom control.
Conclusions: Accurate preoperative diagnosis of liver cystic lesions may be difficult.
However, laparoscopic liver resections for such lesions are safe and provide long-term
symptomatic control in benign disease and may be curative in some cases of underlying
malignancy. Even if almost half of liver cystic lesions treated by resection were either
symptomatic SC or HC, we recommend en-bloc liver resection for all liver cystic lesions
that are not clearly parasitic or SC.

Short-Term Outcome of Laparoscopic Distal Pancreatectomy

Junju Maehara, MD, Koji Asai, Manabu Watanabe, Hiroshi
Matsukiyo, Tomoaki Saito, Tomotaka Ishii, Ryohei Watanabe,
Toshiyuki Enomoto, Natsuya Katada, Yoshihisa Saida, Shinya
Kusachi, Department of Surgery, Toho University Ohashi Medical
Center
Introduction: We analyzed short-term outcome of laparoscopic distal pancreatectomy
(LDP), and also reported on the management of the pancreatic stump.
Patients and Methods: We introduced LDP in 2011, and 10 cases were included in this
study. Pancreatic resection was performed using laparoscopic linear stapler. For every case,
we used a black or green cartridge for more than 10 min. A polyglycolic acid (PGA) sheet
with fibrin glue was wrapped around the pancreatic stump to prevent the occurrence of a
postoperative pancreatic fistula (POPF).
Result: A total of 10 patients (2 male and 8 female; age range, 1076 years; median age,
67 years) underwent LDP. Their final diagnoses were as followed; pancreatic neuroendocrine tumor (three cases), pancreatic ductal adenocarcinoma (two cases), intraductal
papillary mucinous neoplasm, mucinous cystic neoplasm, solid pseudopapillary neoplasm,
serous cystic neoplasm, and chronic pancreatitis. Spleen preserving LDP was performed in
one case; the remaining patients underwent conventional LDP. The operative time was 401
(range, 210600) min, and the estimated blood loss was 66 (02200) g. POPF occurred in
three cases, including two cases of grade A and one case of grade B; thus, one case (10 %)
of clinical POPF (grade B and C) was observed. The other cases did not develop any
postoperative complications [IIIa of the Clavien-Dindo classification.
Conclusion: We reported the results of short-term outcome after LDP, and the management
of the pancreatic stump. Appropriate pancreatic resection with wrapping of a PGA sheet
using fibrin glue may reduce the occurrence of POPF.

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P407

P409

A Case Report: Duplication of Gallbladder

Lessons Learnt in the Management of Liver Incidentaloma:

Peribiliary Gland Hamartoma

Chollada Suwannachod, Dr, Setthasiri Pantanakul, Dr, Siriporn

Angchuan, Dr, Petch Kasetsuwan, Dr, Bhumibol Adulyadej Hospital
Duplication of gallbladder is a very rare congenital malformation that occur in about 1 per 4000
births. Variations of the gallbladder and cystic duct anatomy are associated with an increased risk
of complications during cholecystectomy. Pre-operative diagnosis is rarely made but very
important in order to prevent operative complications. Our report is a case of 42-year-old man with
history of cholangitis. Ultrasound and Endoscopic Retrograde Cholangiopancreaticography
(ERCP) were performed but did not demonstrate his congenital anomaly. During laparoscopic
cholecystectomy we found 3 feeding arteries and a large caliber of cystic duct. Operative time was
135 minutes. Operation was successful without any complication. The duplication of gallbladder
was comfirmed with gross and histological finding.
Conclusion: The critical point of the procedure is a good exposure, to clearly identify critical view
of safety, and make sure before resected both cystic duct and cystic artery in very particular patient
even in the patient with normal imaging.

P408
Evaluation of the Safety and Efficacy of Staging Laparoscopy
for Advanced Pancreatic Cancer
Takanori Morikawa, MD, PhD, Masaharu Ishida, MD, PhD, Hideo
Ohtsuka, MD, PhD, Takeshi Aoki, MD, PhD, Simpei Maeda, MD,
PhD, Kyouhei Ariake, MD, PhD, Kunihiro Masuda, MD, PhD, Koji
Fukase, MD, PhD, Masamichi Mizuma, MD, PhD, Naoaki Sakata,
MD, PhD, Kei Nakagawa, MD, PhD, Hiroki Hayashi, MD, PhD,
Fuyuhiko Motoi, MD, PhD, Takeshi Naitoh, MD, PhD, FACS,
Michiaki Unno, MD, PhD, Department of surgery, Tohoku University
Graduate School of Medicine
Background: It is hard to decide therapeutic strategy for advanced pancreatic cancer, especially in
borderline resectable cases, because of the difficulty to apply the surgical approach and to confirm
clinical stage exactly. Multi-detector computed tomography (MDCT), magnetic resonance imaging
(MRI), and positron emission tomography (PET) have improved staging accuracy of advanced
pancreatic cancers, however, precise evaluation using these diagnostic imaging was limited.
Staging laparoscopy (SL) is one of the useful diagnostic methods and could detect minute liver and
peritoneal metastases which would not be delineated by MDCT, MRI, and PET. Therefore, we
recently introduced SL before surgical treatment or chemotherapy in order to evaluate clinical stage
of advanced pancreatic cancer.
Aim: The aim of this study is to evaluate the feasibility and efficacy of SL as a diagnostic modality
for patients with advanced pancreatic cancer.
Patients and Methods: In our institution, the indication for SL was pancreatic cancer which
abutted to major artery, that is celiac artery, common hepatic artery, splenic artery, and superior
mesenteric artery, or were suspected to develop to micro liver and/or peritoneal metastases. We
reviewed clinical records of patients who underwent SL for advanced pancreatic cancer, and
clinicopathological findings, surgical outcomes, and diagnostic accuracy were retrospectively
analyzed.
Results: From July 2010 to June 2015, 29 patients (M:F = 13:16) underwent SL. Average age was
62.7 10.2 years old and mean tumor diameter was 37.6 15.6 mm. Nineteen patients had
pancreas head carcinoma and 27 patients were preoperatively diagnosed as clinical stage III. Mean
operation time was 62.7 10.2 min and intraoperative blood loss was 3.2 4.7 g. Median
postoperative hospital stay was 5(299) days. Only one patient (3.4 %) experienced postoperative
complication and underwent reoperation due to perforation of the small intestine, and the other 28
cases discharged uneventfully. Twelve patients diagnosed unresectable using SL because of distant
metastases, and three patients diagnosed unresectable due to tumor invasion to major artery.
Remaining 14 patients underwent laparotomy and palliative operation was performed in two
patients due to liver metastasis (n = 1) and carcinomatous peritonitis (n = 1). Thereby, sensitivity
and specificity of SL were calculated to be 85.7 % and 100 %, respectively.
Conclusion: SL is a safe and feasible approach and can prevent unnecessary laparotomy. It is
helpful to use SL as a diagnostic modality to determine treatment strategy in case of borderline
resectable pancreatic cancer.

123

Suresh Khanna Natarajan, MD1, Tzu Jen Tan, MD2, 1Khoo Teck
Puat Hospital/ NHG-AHPL General Surgery residency program,
2
Khoo Teck Puat Hospital
Introduction: Accidentally detected asymptomatic liver tumors have been named as Incidentalomas; the incidence of which is 1050 %. Unfortunately, their histological nature is rarely
proven by one method of imaging and even sophisticated technologies do not clear the doubt in
1040 %.
A very rare case of Peribiliary Gland Hamartoma (PGH) was found incidentally during uncomplicated laparoscopic cholecystectomy and we discuss here its management, complications and also
the issues involved in such cases.
Case Report: 83-year-old female presented with acute cholangitis due to cholelithiasis/ choledocholithiasis and underwent ERCP. CT abdomen showed non-enhancing hypodense lesion in
Segment 4b of liveran early abscess. Four weeks later, she had a laparoscopic cholecystectomy
and intra-operative cholangiogram, during which a 3 cm, white, smooth lesion was noted at free
edge of left liver lobe.
Laparoscopic intra-operative ultrasound showed that the lesion was solid. Hence a laparoscopic
Trucut biopsy was done. Incidentally brisk bleeding was noted in anterior surface of left lobe,
34 cm away from biopsy site, which was secured by hook diathermy and laparoscopic suturing.
Post-operatively, the patient developed hypotension & rapid decline in haemoglobin level.
Emergency CT mesenteric angiogram showed contrast blush from anterior branch of left hepatic
artery, which was embolized with gel foam and coil. Patient was stable after. Histopathology was
reported as PGH.
Discussion: Currently, there are no evidence-based guidelines regarding appropriate approach to
diagnosis, interpretation of imaging and indication for surgical resection for incidentalomas.
PGH, also known as intrahepatic bile duct adenoma, cholangioma, benign cholangioma, cholangioadenoma or simply bile duct adenoma, is a rare benign epithelial hepatic tumor originating from
bile duct cells usually discovered incidentally at autopsy or laparotomy with an incidence of 1.3 %.
Pathogenesis of PGH is still unclear but it is considered a reactive process to focal bile ductular
injury caused by trauma or inflammation rather than true neoplasm.
The issues here are: whether to biopsy incidentaloma and availability of frozen section. If lesion is
reported as benign it may be followed up, whereas if report is malignant, then it cannot be resected
during same operation owing to incomplete work-up for a major operation, consent issues,
availability of expertise and technical support. Also to be considered are possibility of unfortunate
complication due to biopsy (like our patient) and managing the same. Later radiology may be the
only means of assessing the lesion, which may not be reliable in some rare cases. Percutaneous
image-guided biopsy is controversial in itself.

P410
Antibiotic Prophylaxis is Necessary for Elective Laparoscopic
Cholecystectomy ?
Pinnara Manokit-udom, Dr, Panot Yimcharoen, Dr, Setthasiri
Pantanakul, Dr, Poschong Suesat, Dr, Petch Kasetsuwan,
Dr, Bhumibol Adulyadej Hospital
Background: Although laparoscopic cholecystectomy (LC) has low rate of wound infection, the
prophylactic antibiotic has been routinely used for prevent infection. The aim of this study was to
compare surgical site infection rate between the patients who received and who did not receive
prophylactic antibiotic in elective LC.
Materials and Methods: From May 2014 to July 2015, there were 169 patients underwent elective
laparoscopic cholecystectomy (LC) in our institute. The patients with symptomatic gallstones and
ASA class 1- 2 were included into this study. Patients who had history previous hepatobiliary tract
infection (cholecystitis, chloangitis) and/or biliary endoscopic intervention within 3 months before
LC were excluded. Demographic data, indication for surgery, type of antibiotic, intra-operative bile
spillage, bile culture and post-operative wound infection were recorded. Patients were divided into
2 groups; group A: the patients who underwent LC with third generation of cephalosporin antibiotic
prophylaxis and group B : the patients who underwent LC without prophylactic antibiotics. Bile
culture from gallbladder was taken in all cases. The wound was observed and followed up within a
month.
Results: Forty-eight patients were randomized and included into this study. In group A, there were
24 patients (7 M, 17 F), mean age 59.1 13.2 years (3486). In group B, there were 24 patients
(10 M, 14 F), mean age 58.7 15.2 years (2679). During surgery, we had 7 cases of accidental
ruptured gallbladder in group A and 2 cases in group B. The post operative wound infection
developed in 1 case of group B (4.2 %) and no patient developed wound infection in group A
(0 %). The overall, 13 patients (7 in group A and 6 in group B) had positive bile cultures (27 %).
The commonest pathogen was Escherichia coli (6 in 13 patients, 46.2 % of positive culture).
Conclusions: There was no statistical significant difference in surgical site infection between both
groups (p = 0.32). This study has small sample size, however better study design with more
population is in the process of recording and reviewing.

Surg Endosc (2016) 30:S325S500

S431

P411

P414

Perioperative Hepatocyte Growth Factor (HGF) Infusions

Increase Liver Volumes Following Portal Branch Ligation (PBL)

Outcome of Laparoscopic Necrosectomy in 15 Patients

with Infected Pancreatic Necrosis

Christopher W Mangieri, MD, Jason C McCartt, MD, Matthew

A Strode, DO, John E Lowry, DVM, Prasad M Balakrishna, PhD,
Dwight D. Eisenhower Army Medical Center

Prabhdeep Nain, Prof, Satpal Virk, DAYANAND MEDICAL

COLLEGE & HOSPITAL, LUDHIANA

Background: It is ideal to treat hepatic tumors with primary resection versus transplantation. A clinical
adjunct to facilitating primary resection is portal vein embolization (PVE). Hepatic tumors that are too large
for initial primary resection undergo PVE to induce hypertrophy of the liver that will not be resected
allowing for sufficient post-operative liver volumes. Hepatocyte growth factor (HGF) is one of the strongest
trophic factors for hepatocyte regeneration. The purpose of this study was to increase liver volumes with
perioperative HGF infusions in an animal model that mimics PVE.
Methods: Portal branch ligation (PBL) in rodents is equivalent to the clinical practice of PVE in humans.
We performed left-sided PBL in Sprague-Dawley rats with the control group receiving normal saline
infusions and the experimental group receiving HGF infusions. Prior to performing PBL we established
baseline liver volumetrics with CT scanning methods. We then repeated CT liver volumetrics following
PBL to observe for differences in post-PBL liver volumes.
Results: The control and experimental rats had identical baseline liver volumetrics. The experimental rats
undergoing perioperative HGF infusions had statistically significant increases in all post-operative liver
volumetrics. Most clinically relevant were increased right liver volumes (RLV), 14.10 cm3 versus 7.85 cm3
(p value 0.0001), and increased degree hypertrophy (DH %), 159.23 % versus 47.11 % (p value 0.0079), in
the remaining viable liver.
Conclusion: Perioperative HGF infusions significantly increase hepatic regeneration following PBL. HGF
infusions following PVE is a possible adjunct to increase the amount of patients able to successfully undergo
a primary liver resection. Future basic science is warranted in examining the use of HGF in that regard and
potentially translating that basic science work to clinical practice.

Introduction: Infected pancreatic necrosis is a life-threatening complication of acute pancreatitis that has
been traditionally managed with open surgical debridement.
Treatment of pancreatic necrosis has evolved considerably over the past decade with respect to both the
timing of intervention & the development of alternatives to traditional open necrosectomy.
Aims and Objectives: To study the outcome of laparoscopic pancreatic necrosectomy performed in patients
with infective pancreatic necrosis in terms of; Morbidity (GI fistula, haemorrhage, recurrence/ intervention).
Length of stay (ICU, hospital) Mortality.
Results: We studied the outcome of 15 cases of infected pancreatic necrosis managed by laparoscopic
pancreatic necrosectomy as regards morbidity, length of stay & mortality.
In present study transperitoneal approach access to lesser sac, right and left paracolic gutter, perinepheric
space, retroduodenal space & root of mesentery was accomplished for drainage.
Each patients treatment was individualized & preoperative CT scan guided the approach.
Stay of patients was average 8 days, 10 developed pancreatic fistula, all required irrigation which was taught
to patients relatives.
2 patients required laparotomy. 2 others required pigtail drainage of residual collections by CT guided
radiological drains.
There was one mortality.
Conclusions: Laparoscopic necrosectomy is a feasible procedure in acute infected pancreatic necrosis. We
report similar rate of complications as open necrosectomy but with less morbidity to the patients.

P415
P413

Clinical Study of the Accuracy of Observing Common Bile Duct

Remnant Stones by Injection of Saline Through ENBD Under
the Guidance of Ultrasound

Role of Intraoperative Confocal Endomicroscopy for the realtime Characterization of Tissues During Laparoscopic
Procedures
1

Angelo Pierangelo , David Fuks , Abdelali Benali , Pierre Validire ,

Brice Gayet2, 1Ecole Polytechnique Paris, France, 2Department
of digestive diseases, Institut Montsouris, Paris, France, 3Department
of pathology, Institut Montsouris, Paris, France
Introduction: Probe-based Confocal Laser Endomicroscopy (CLE) represents an innovative technique
providing real-time, in-vivo optical biopsies. It has been used in a wide range of applications, e.g. gastrointestinal endoscopy, urology and pulmonary endoscopy procedures. The aim of this study was to assess
the role of intraoperative CLE for the characterization of intra-abdominal organs during laparoscopic
procedures for digestive cancers.
Methods and Procedures: Between October 2014 and July 2015, all consecutive patients with digestive
cancer planned for a surgical resection were prospectively enrolled. The study was approved by an ethical
committee. Real-time images of both healthy and malignant tissues were acquired by a motorized confocal
ultra high definition (UHD) mini-probe with a bending distal tip providing easy access to abdominal organs.
It was connected to a dual wavelength endomicroscopy system that allowed imaging in the near-infrared, at
785 nm (with Indocyanine Green). A live audio-visual transmission was established during the procedure
between the surgeon and the pathologist for real-time interpretation of optical biopsies. Intravenous injection
or topical application of contrast agent was performed few seconds before imaging. Results of optical
biopsies were compared to the definitive histopathological analysis that was considered as the reference.
Results: Thirty patients (n = 14 male, mean age of 66 1,7 years) were included. CLE was successfully
performed with intraoperative imaging on the following organs: lymph node (n = 4), peritoneum (n = 15),
liver (n = 16), colon/rectum serosa (n = 5), pancreas/pancreatic duct (n = 4), stomach (n = 3), ovary
(n = 1), adrenal gland (n = 1). Live transmission between the surgeon and the pathologist was successful in
16/30 cases, connection issues were encountered in 4 cases but which communication remained possible.
Two (6 %) adverse events, non related to the device tested were reported and 4 technical issues were
encountered with the confocal miniprobe. According to criteria of malignancy previously described with
ICG staining, the specificity and the negative predictive values of intraoperative CLE for the diagnosis of
malignancy in the peritoneum were both 100 %. However, the sensitivity only reached 50 % (3 cancers out
of 8 were detected). In the liver, it was not possible to visualize malignancy in any of the metastasis. The
reasons have been identified e.g. probe optical characteristics, thickening of the liver capsule due to cancer
and/or chemotherapy.

Yan-Bo Liu, Shuo-Dong Wu, Department of the Second General

Surgery, Shengjing Hospital of China Medical University, Shenyang
City, Liaoning Province, Peoples Republic of China
Objective: To investigate the accuracy of observing commo bile duct (CBD) remnant stones by injection of
saline through endoscopic nasobiliary drainage (ENBD) under the guidance of ultrasound.
Methods: ENBD was routinely placed in 58 patients with CBD stones who underwent endoscopic stone
extraction. Ultrasound examination was performed 3 to 5 postoperative days. After routine examination by a
professional ultrasound doctor, 50200 ml saline was injected through ENBD slowly. Ultrasonic results,
including changes of bile duct diameter and detection rate of CBD remnant stones, was compared.
Results: Among the 58 patients, CBD remnant stone was detected in 1 patient before injection and failure of
injection occurred in 1 patient due to the damage of ENBD; 2 patients showed bad tolerance of abdominal
pain after injection of 20 ml saline. No significant change of the diameter of the CBD after injection was
observed in 1 patient, while obvious dilation of the diameter of the CBD was observed in the other 56
patients after injection. In these 56 patients, the lower end of the CBD which is interfered by intestinal gas
before injection appeared more clearly after injection. Of the 57 patients who underwent injection, CBD
remnant stones were detected in 6 patients with the detection rate 10.5 %(6/57), which was significantly
increased compared with the detection rate 1.72 %(1/58) before injection.
Conclusions: The accuracy of observing CBD remnant stones by injection of saline through ENBD under
the guidance of ultrasound is significantly improved..
Key words: Common bile duct remnant stones; Ultrasound; ENBD; Saline injection

Conclusions: Intraoperative CLE with a dedicated motorized confocal miniprobe and a near infra-red
illumination is feasible and safe during laparoscopic procedures. These results suggest that CLE could
provide additional information intraoperatively for peritoneal characterization with live remote support of
pathologists.

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P416

P417

Precise Laparoscopic Anatomical Liver Segmentectomy

by Extrahepatic Hilar Approach with 3D Computer-Assisted
Simulation and Navigation

Clinical Feasibility of Laparoscopic Central Bisectionectomy

Yuta Abe, MD, Osamu Itano, MD, Masahiro Shinoda, MD,

Minoru Kitago, MD, Hiroshi Yagi, MD, Taizo Hibi, MD,
Yuko Kitagawa, MD, Department of Surgery, Keio University School
of Medicine
Aim: Theoretically, anatomical liver resection requires in-depth understanding of liver
anatomy and is technically demanding even by laparotomy. We describe our series of pure
laparoscopic anatomical liver segmentectomies using 3D computer-assisted simulation and
navigation.
Methods: Precise preoperative evaluation by 3D imaging enabled us to identify each portal
pedicle and hepatic vein at the tertiary levels and simulate the cutting plane of the liver
while securing adequate tumor margins. In the operating room, we started from isolating the
main inflow portal pedicles to the tumor at the hepatic hilum (extrahepatic hilar approach),
which could be done easily with the magnified view of laparoscopy. Then, the transection
of the liver parenchyma followed the demarcated line by selective clamping of portal
pedicles. Once we get inside the liver, the small branches of hepatic veins, which were
already identified preoperatively, served as beacons of the boundaries between the resecting
liver and the remnant.
Results: During the period between 2013 and 2014, 93 patients with liver tumors underwent laparoscopic liver resections and of 17 patients (Rt liver: 14, Left liver: 3) underwent
laparoscopic liver segmentectomies by extrahepatic hilar approach. We successfully performed pure laparoscopic liver resections by identifying all anatomical structures and
reproducing the transection plane that was planned preoperatively in all cases. Median
number of tertiary glissonean pedicles ligated was 2 (14) and median estimated blood loss
was 200 (0550). Surgical margins were all negative.
Conclusion: With the combination of precise understanding of the vascular anatomy using
3D imaging and the luxury of magnified view as well as decreased blood loss by laparoscopic surgery, we can now perform a more accurate, truly anatomical liver resection
according to each tumor location. Pure laparoscopic liver resection and 3D computerassisted simulation and navigation has taken anatomical liver resections to the next level.

123

Sung Hoon Choi, MD, CHA Bundang Medical Center, CHA

University
Introduction: Laparoscopic central bisectionectomy (LCB) for centrally located tumor has
been rarely attempted. It is come from a technical difficulty due to two different surgical
plane and extensive parenchymal transection area resulting long operative time.
Methods: From April 2014 to August 2015, four of 9 patients underwent central bisectionectomy were performed with a laparoscopic procedure. The initial perioperative
outcomes of the laparoscopic group and open group were compared. The laparoscopic
procedure was set up as laparoscopic posterior sectionectomy. The patient was placed
supine in a reverse Trendelenburg position with right elevation. Four trocars were used and
a rubber band self-retraction technique was applied for the two different resectional planes
respectively.
Results: There were no conversions to open surgery in the laparoscopic group. The mean
operative time in the laparoscopic group was longer to that in the open group (395 57 vs.
288 23 min, respectively, p = 0.007). Intraoperative blood loss was less in the laparoscopic group compared with the open group (1100 336 vs. 960 288 ml, p = 0.522),
There was no difference in the surgical margin (0.45 0.5 vs. 0.64 0.22 cm,
p = 0.470). The length of stay after surgery was shorter in the laparoscopic group
(8.7 1.2 vs. 12.6 4.4 days, p = 0.141). There was no difference in the rate of postoperative complications between the two groups (1 vs. 1 cases).
Conclusion: LCB is still demanding procedure with long operative time. However, this
procedure is feasible and safe in regard to short-term perioperative outcomes. LCB may
provide several benefits commonly attributed to minimally invasive surgery in selected
patients.

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Super-Selective Intra-Arterial Indocyanine Green Injection

for Positive Fluorescence Image Guided Hepatic Segments
Staining: Proof of the Concept in the Porcine Model

The Introduction of Enhanced Recovery After Surgery

in Laparoscopic Liver Resection

Michele Diana, MD1, Yu-Yin Liu, MD2, Raoul Pop, MD3, Seong-Ho
Kong, MD1, Andras Legner, MD1, Remy Beaujeux, MD, PhD3,
Patrick Pessaux, MD, PhD4, Didier Mutter, MD, PhD, FACS4,
Bernard Dallemagne, MD5, Jacques Marescaux, MD, FACS, Hon,
FRCS, Hon, FJSES, Hon, APSA5, 1IHU-Strasbourg, Institute
for Image-Guided Surgery, Strasbourg, France, 2Department
of General Surgery, Chang Gung Memorial Hospital, Chang Gung
University, Linkou, Taiwan, 3Interventional Radiology Department,
University Hospital of Strasbourg, Strasbourg, France, 4Department
of General and Digestive Surgery, University Hospital of Strasbourg,
Strasbourg, France, 5IRCAD, Research Institute against Cancer
of the Digestive System, Strasbourg, France
Background: Intraoperative liver segmentation can be obtained by fluorescence imaging
using near-infrared cameras and injecting a fluorophore, e.g. Indocyanine Green (ICG),
either systemically (negative staining) after clamping the pedicle of the targeted segment,
which will appear non-fluorescent, or by percutaneous injection (positive segment) in the
corresponding portal branch. Positive staining provides clearer demarcation lines, but the
percutaneous approach is often complex. We aimed to evaluate the feasibility of fluorescence liver segmentation by superselective intra-hepatic artery injection of ICG.
Materials and Methods: Eight pigs (mean weight 26.01 5.21 kg) were involved. Procedures were performed in a hybrid experimental operative suite equipped with the Artis
Zeego multi-axis robotic angiography system. Four animals served to establish the feasibility of intra-arterial ICG injection for segment demarcation. A pneumoperitoneum was
established and 4 ports introduced in the abdominal cavity. Through a femoral artery
approach, the celiac trunk was cannulated under angiographic control and a microcatheter
was advanced into different segmental hepatic artery branches: sub-segmental (n = 1),
segmental (n = 1), bi-segmental (n = 1), tri-segmental (n = 1). In each case, 4 escalating
doses of ICG were injected (0.001; 0.01; 0.1 and 1 mg/ml) via the arterial catheter. The
injected volume was 1 ml every 15 minutes. A near-infrared laparoscope (D-Light P; Karl
Storz) was used to detect the fluorescent signal. In 3 additional animals, only sub-segments
were targeted. A series of metallic markers was placed in the liver parenchyma following
the fluorescent demarcation and a 3D CT scan was performed after injecting intra-arterial
radiologic contrast, to confirm the correspondence between the fluorescence demarcation
and the volume of the liver fed by the artery (Fig. 1). In one control animal, simultaneous
percutaneous intra-portal angiography and intrarterial angiography were performed to
verify the correspondence of the territory served, and escalating doses of ICG were injected
in the portal branch.
Results: Bright fluorescence signal enhancing the demarcation of target segments was
obtained from 0.1 mg/ml, in matter of seconds. Correspondence between the hepatic segments volume and the arterial territories was confirmed by CT angiography after
fluorescence-guided laparoscopic marking. Positive staining by intraportal ICG injection
was limited by a higher background fluorescence noise, due to the parenchymal accumulation of ICG and porto-systemic shunt.
Conclusions: Fluorescence videography by intrahepatic arterial ICG injection highlights
rapidly hepatic segments demarcation and with a better signal-to-background ratio than by
portal vein injection. This technique seems promising and should be assessed in the clinical
setting.

Shingo Ishida, Masayasu Aikawa, Santosh Shrestha, Takuya Katou,

Katsuya Okada, Yukihiro Watanabe, Kojun Okamoto, Hiroshi Satou,
Mitsuo Miyazawa, Shinichi Sakuramoto, Shigeki Yamaguchi, Isamu
Koyama, saitama medical university international medical center
Objective: Laparoscopic liver resection (LLR) is a rapidly spreading in recent years,
however, there is not an obvious evidence yet that it is minimal invasive. In this study, we
have introduced the Enhanced Recovery After Surgery (ERAS) in the LLR cases and
evaluated the possibility and the safety.
Methods: Of the 170 LLR cases we have performed in our institution from January 2008 to
July 2015, 5 cases were included in ERAS program as an approved study. The conditions
for the participation in this study was set to be, a scheduled laparoscopic partial hepatectomy, an expected operation time of less than 4 hours, without serious complications, under
80 years of age, and the consent of the study obtained. The outline of the program is,
performing LLR under general anesthesia without epidural block, standing at the bedside in
3 hours, and drinking water in 4 hours after operation, starting liquid diet in the evening of
the operative day. In addition to the background of the patients, operative duration, volume
of blood loss, post-operative pain, post-operative level of consciousness, post-operative
complications, and hospital stay were the parameters included for evaluation. These
parameters were compared between the cases that could continue the program and the cases
that were dropped from the program.
Results: Of the 5 cases, 2 cases were dropped from the program because they failed to stand
at the bedside in 3 hours after operation. Both of the cases were older than 75 years of age.
There was no trouble due to the participation to the program. As far as the three cases that
could complete the program are concerned, there was no significant difference in perioperative factors, in comparison to other LLR performed in our institution. However, there
was a tendency of a shorter hospital stay.
Conclusion: It was suggested that ERAS could be introduced in LLR safely, and could
shorten the hospital stay if we set up a selection criteria such as age.

Fig. 1 .

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Analysis of Outcome of Laparoscopic Cholecystectomy (Based

on Duration and Severity)

Laparoscopic Liver Resection for Hepatocellular Carcinoma

in Cirrhotic Patients

Manoj Kr. Choudhury, GNRC Hospitals

Ibrahim A Salama, MDPhD, Hosam Soliman, Hazem Zakeria,

Mohammed Aboushady, Department of Hepatobiliary Suregry,
Menoufiyia University, Egypt

Introduction: Laparoscopic cholecystectomy in acute cholecystitis within 72 hrs has been

the accepted practice, but lap chole beyond 72 hours has not been accepted due to increased
risk of complications. Patients from periphery in our part of the world reach late for
treatment due to poor connectivity, economic backwardness, and lack of awareness and
pose a treatment dilemma. We took up these cases with various durations and severity and
performed laparoscopic cholecystectomy to analyze the results and outcome.
Method and Procedure: 843 cases of acute cholecystitis out of 3560 lap. Chole performed
during the period from September, 2008 to august, 2015 were taken up for analysis.
Choledocholithiasis, acute pancreatitis and those who refused early surgery were excluded
from the study.
After complete work up, cases were categorized as acute (upto 7 days) and unresolved
acute cholecystitis (7 days to 2 months) and others (60 days onwards). Severity was
classified as mild, moderate and severe (Tokyo guideline). Ultrasound was the routine
diagnostic test. CT scan and MRI was done in selected cases Acute cholecystitis with signs
of sepsis was treated with antibiotics for 48 hours prior to surgery. Patients with organ
dysfunction were stabilized by multi-disciplinary team. Lap Cholecystectomy was performed with four ports technique. Duration of surgery, complications and the hospital stay
were recorded.
Results: Male and female ratio was 38.22 % and 61.78 % respectively. Record showed
280(33.17 %) cases were acute, 366 (43.41 %) unresolved acute cholecystitis (7 days to
2 months) and 197(23.41 %) cases (60 days onwards). As per Tokyo 2007 guide line 584
(69.27 %) mild, 201 (23.90 %) moderate, 58 (6.83 %) severe cases were found. Duration of
surgery performed within 60 minutes was 48.9 % in acute cases (96.1 % Routine LC). We
had two billiary injury in acute group, overall converted 3 cases and had post operative
sepsis 3 cases. Av. Hospital stay was 2 days (15 days)
Conclusion: We did not find significant difference in results of treatment in regards to
duration of symptoms and severity. No significant difference was noted in complication and
conversion rate. Duration of surgery and hospital stay differed significantly in acute,
unresolved and elective category. (p value being 0.0001)

123

Background: The optimal treatment for Hepatocellular Carcinoma is surgical resection. However, only a small percentage of patients are operative candidates due to
associated liver cirrhosis. With progress of technology, laparoscopic liver resection in
cirrhosis becomes challenge.
Aim: To assess the feasibility and safety of laparoscopic liver resection in cirrhotic patients.
Patients and Methods: This is a prospective study on 46 patients with HCC with cirrhosis
referred from HCC clinic at National Liver Institute, Menoufyia University. Hepatic
involvement had to be limited in the left lobe or peripheral right lobe segments (segment
26). Tumor had to be 5 cm or less. Laparoscopic hepatic resection was done with a
harmonic scalpel and or Habib 4 X needle without porta hepatis clamping. Staplers were
used on the portal triad and hepatic veins.
Results: From July 2011 to July 2015, 46 patients of HCC with cirrhosis (18.5 %) out of
248 patients were subjected to laparoscopic liver resection in cirrhotic liver (Child A &
early B). Laparoscopic resections including 14 segment III, 6 segment II, 5 bisgmentectomy
II&III, 3 segment IVB, 5 segment V and 13 segment VI. There were 4 conversions to open
due to uncontrolled bleeding. Mean operative time 130 minutes. There was one mortality
due to liver cell failure, and morbidity in 4 patients (2 ascitis, 1 Bleeding, 1 pneumonia).
Negative safety margins in all patients with no recurrence in follow up period
(633 months).
Conclusion: With excellent use of existing technology Laparoscopic liver resection become
feasible and safe options in cirrhotic patients with liver tumors.

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Validity of Laparoscopic Liver Resection for Hepatocellular

Carcinoma with Severe Liver Dysfunction

A Novel Inflatable and Retracting Laparoscopic Device

that Provides Maximal Exposure of the Operative Field

Masayasu Aikawa, MD, Mitsuo Miyazawa, MD, Shingo Ishida, MD,

Yukihiro Watanabe, MD, Katsuya Okada, MD, Kojun Okamoto, MD,
Shinichi Sakuramoto, MD, Shigeki Yamaguchi, MD, Isamu Koyama,
MD, Saitama Medical University, International Medical Center

Ambar Mehta1, Anirudh Dwarakanath, MS2,

Rohith M Bhethanabotla3, Hien T Nguyen, MD2, 1Johns Hopkins
University School of Medicine, 2Johns Hopkins Bayview Medical
Center Department of Surgery, 3Johns Hopkins University Krieger
School of Arts and Sciences

Introduction: Surgical resection is the most effective treatment method for hepatocellular carcinoma (HCC). However, surgical resection of HCC is
often avoided because of the risk of liver dysfunction. We believe that laparoscopic liver resection (LLR) is less invasive and thus more effective for
preserving liver function. Therefore, we introduce the use of LLR for HCCs with severe liver dysfunction (Child-Pugh class B or C), which are
considered to be unresectable in other facilities.
In this study, we identified the advantages and limitations of using LLR for HCC with severe dysfunction in our facility, and determined the validity
of LLR in comparison with open surgery for HCC with severe dysfunction.
Methods: Total LLR was performed in 180 patients between January 2008 and September 2015 at the Department of Gastrointestinal Surgery of
Saitama Medical University International Medical Center, Saitama, Japan. LLR, as partial resection, was performed in 49 patients with severe liver
dysfunction. The other group included cases treated with open partial liver resection (OLR) for HCC with severe dysfunction, before LLR was
introduced. Our indication for LLR was decided according to patient performance status, tumor size of\4 cm, and tumor location on the surface. We
performed liver resection under minimal mobilization and incision without the Pringle maneuver.
Results: The patients backgrounds did not significantly differ between the LLR and OLR groups. None of the patients who underwent LLR required
conversion to laparotomy. The operative duration was 206 min (range, 50470 min) in the LLR group and 175 min (45355 min) in the OLR group,
with no significant differences between the groups. Blood loss, AST peak value, and duration of hospital stay were 30 cc (0850 cc) and 550 cc
(301700 cc), 254 IU/L (801964 IU/L) and 359 IU/L (491601 IU/L), and 6 days (221 days) and 11.5 days (658 days) in the LLR and OLR
groups, respectively; all these values significantly differed between the groups. Postoperative complications of Clavien-Dindo classification grade III
or higher occurred in 2 cases in the LLR and 4 cases in the OLR group. No significant differences in surgical margin positivity rate and postoperative
survival duration were observed between the LLR and OLR groups.
Conclusion: LLR was found to be safe and valid for the treatment of appropriately selected cases of HCC with severe liver dysfunction. Thus, we
suggest LLR can serve as a novel treatment strategy for HCC with severe liver dysfunction.

Objective: To evaluate the safety and feasibility of LapSpace, an innovative, FDA-cleared, laparoscopic device with an inflatable element that can
retract abdominal contents for creating and maintaining optimal exposure of the operative field, a necessity for successful laparoscopic procedures.
Description: For any laparoscopic surgery to be efficient, surgeons require optimal and stable exposure of the surgical field. Currently, maneuvers
such as the Trendelenburg as well as metallic instruments are used to clear abdominal organs and other abdominal contents from the operating field.
These methods unfortunately are only partially effective and can cause unintentional trauma. For example, abdominal contents often slide back into
the operating field, and excessive manipulation of abdominal organs can lead to preventable complications. The LapSpace laparoscopic retractor is
placed through a 10-mm trocar and controls an inflatable balloon at its tip. Once the device is inside the abdomen, the surgeon inflates the balloon
and can control its positioning and retraction angle. A bed clamp provides permanent retraction and hands-free utilization. The balloon itself is a
biocompatible polymer, made of nylon fibers and thermoplastic polyurethane, which is atraumatic to tissue and can hold sufficient tension and
pressure. The retractor minimizes mobilization of the small intestines and stabilizes the abdominal organs.
Results: Eleven surgeons have utilized this device for more than 50 surgeries, including at least three total hysterectomies, one cholecystectomy, ten
sleeve gastrectomies, one ileal interposition, two Nissen fundoplications, one adrenalectomy, and thirteen herniorrhaphies. A 15-question survey
collected the surgeons feedback on the devices safety, utility, ergonomics, and satisfaction. The surgeons overwhelmingly stated that this device
provides optimal exposure of the operating field, minimizes risks of inadvertent tissue injuries, and reduces the tilt or the time spent by the patient in
the Trendelenburg position. Each surgeon was satisfied with the ergonomics of the handle and noted that they would use the device again. One
surgeon experienced minor difficulties with deflating the balloon completely.
Conclusions: The LapSpace inflatable retractor, with its novel inflatable component and manually-controlled retractor, has initially demonstrated
versatility in a wide variety of operations, in providing an optimal operating field, and in reducing inadvertent tissue injuries. Due to the utility of this
device, there is potential for it to become commonly used in many different types of minimally invasive procedures. This pilot study warrants further
investigation into how this device can improve on efficacy, time, and costs of laparoscopic operations.

P423
Report of the Measurement of Physical Burden on Surgeons
Upper Limbs During Laparoscopic Surgery
Ryota Nakajima1, Hiroshi Kawahira2, Shimomura Yoshihiro3, Wataru
Nishimoto1, Takeshi Saito4, Hisashi Gunji5, Chisato Mori6, Hisahiro
Matsubara5, 1Graduate School of Medical and Pharmaceutical
Science, Chiba University, 2Center for Frontier Medical Engineering,
Chiba University, 3Division of Design Science, Graduate School
of Engineering, Chiba University, 4Department of Pediatric Surgery,
Graduate School of Medicine, Chiba University, 5Department
of Frontier Surgery, Graduate School of Medicine, Chiba University,
6
Department of Bioenvironmental Medicine, Graduate School
of Medicine, Chiba University
Introduction: The physical burden on upper limbs of laparoscopic surgeons has been noticed coming from the limit of the forceps operation by the
abdominal trocars and longer surgery time than open laparotomy. Particularly, the assistant conducts intermittent maintenance of the upper limbs
abduction to keep the surgical field. We hypothesized that those movement was one factor of the burden and evaluated the fatigue of the deltoid
muscles by the electromyograph and posture sensor measurement using technique of the biomedical measurement objectively.
Methods and Procedures: We measured the surface electromyograph (EMG) on both sides of deltoid muscles and the abduction angle of upper
limbs during the simulation of laparoscpic distal gastrectomy on animal: male swines, 30 kg. Procedure of the simulation accomplished by one
experienced surgeon (HK). EMG and the posture sensor measurement used BIOPAC MP150 Data Acquisition Hardware, and the data analysis used
AcqKnowledge4.1 & Analysis Software (Zero C Seven, Inc, Tokyo, Japan). The arm abduction angle can be measured by two posture sensors
located on both of outside upper limbs.
Results: From the results of EMG, the deltoid muscle activity was constant. The situation that maintained an isometric contraction more than
10 %MVC was found, and physical burden by the laparoscopic surgery was confirmed to both operators and assistants. From the results of the
abduction angle, the assistants upper limbs showed more frequent abduction and higher load than the operators.
Conclusion: We confirmed continuous fatigue of the upper limb during laparoscopic distal gastrectomy and suggested that physical burden level of
assistant surgeons were highly loaded.

P425
Appraisal of a Novel Atraumatic Retractor for Laparoscopic
Surgery
Conor OShea1, Emmet Andrews, MD2, Micheal O Riordain, MD3,
Padraig Cantillon-Murphy1, 1University College Cork, 2Cork
University Hospital, 3Mercy University Hospital
Introduction: This study aims to appraise the benefit and usability of a novel, atraumatic retractor in minimally invasive surgery. The retractor,
SecuRetract, may be introduced into the peritoneal cavity through a 5 mm trocar, curved to create a hooking profile and inflated to create a soft
cushioned interface. The most common method used to retract the bowel involves placing the patient in a steep head-down position known as the
Trendelenburg position (TP) and using bowel graspers to manipulate the bowel. Prolonged TP significantly increases the risk of intraoperative
complications especially in obese, elderly, or debilitated patients. Furthermore, the small tips on the bowel graspers can generate high pressures
locally on the soft tissue, which may lead to injury or perforation. SecuRetract has the potential to ease surgical procedures by providing dynamic,
atraumatic control over bowel retraction enhancing operational access as well as improving patient outcomes.

Methods and Procedures: SecuRetract was presented to 24 surgeons across multiple specialities who were surveyed for utility and clinical benefit
of SecuRetract in practice. The survey sought to identify what if any additional laparoscopic procedures SecuRetract may be applicable to, the
potential frequency of use, and any further feedback on design and functionality.

Results: 92 % of colorectal surgeons would use SecuRetract pending further clinical results. Two surgeons did not see a clinical benefit from
SecuRetract. However both were open surgeons and do not perform laparoscopic procedures. 85 % would use SecuRetract at least once every
2 weeks. Colectomy (95 %) and rectal surgery (73 %) are the most immediate applications but a much broader spectrum of potential clinical
indications were cited to include (e.g. bariatric 37 %, gastrectomy 23 % and splenectomy 18 %). The congress identified 16 surgeons who were
willing to champion the technology as early adopters. This direction corresponds to Key Opinion Leaders feedback in Ireland and the US which
suggests that SecuRetract is best utilised in lower abdominal laparoscopic surgery.
Conclusions: One on one interviews with 24 colorectal surgeons identified a clear appetite and clinical need for a minimally invasive retractor.
Attributes which were cited as providing most value were the large curved and inflatable profile at the active distal end, and the small external profile
when deflated to facilitate access through a 5 mm instrument port. A more detailed usability assessment is required to comprehensively assess
functional feasibility. However initial survey results point to a promising disclosure warranting further exploration.

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Usefulness of the Surgical Chair Supporting Operators Knees

1

Wataru Nishimoto , Hiroshi Kawahira , Yoshihiro Shimomura ,

Masaaki Itoh4, Yuji Nishizawa4, Takashi Miki5, Hisahiro Matsubara6,
1
Graduate School of Medical and Pharmaceutical Science, Chiba
University, 2Center for Frontier Medical Engineering, Chiba
University, 3Division of Design Science, Graduate School
of Engineering, Chiba University, 4Department of colorectal surgery,
National Cancer Center Hospital East, 5Department of Medical
Physiology, Graduate School of Medicine, Chiba University,
6
Department of Frontier Surgery, Graduate School of Medicine,
Chiba University
In laparoscopic surgery, surgeons are forced to observe a monitor closely and also keep upright posture, and
it is considered that they are factors of surgeons burden. It has been known that operators realized burden
reduction and the operations accuracy was improved when they were sitting. We developed the surgical
chair to retain operators lower limbs by supporting their knees and analyzed the effects.
Laparoscopic surgeons used the newly developed chair for colorectal surgery. After surgery, we asked the
surgeons to fill out questionnaire for their impression. We also got the both sides of gastrocnemius muscles
potential during the surgery. In addition we analyzed the electromyogram and evaluated the muscle burdens
of the lower limbs. The measurement is done at gastrocnemius surface electromyogram. We converted the
obtained data to root mean square (RMS) and calibrated by the maximum voluntary electroactivity, and
compared the average of every 10 minutes by the significance test.
In case the subjects used the chair, the amplitude of the electromyogram was significantly smaller at the left
legs medial head of gastrocnemius muscle, but larger at the right legs lateral head.
Considering this results, surgeries also operate a foot switch by a right leg thus the chair became an obstacle
to the operation and the burden of the right leg was increased. On the other hand, the left leg that is the pivot
foot was effectively reduced the burden for a long time to put the weight by the chair.
We are investigating the hardness of the chair. For a biological measurement, we are going to measure the
burden of the lumbar muscle and the intervertebral disk.

Incidental Finding of GIST in Morbidly Obese Patients

Undergoing Laparoscopic Sleeve Gastrectomy
A Mooney, MD, S McNatt, MD, M Powell, MD, A Fernandez, Wake
Forest University
Background: Gastrointestinal stromal tumor (GIST) is reported as a rare neoplasm in the
general population with an incidence of 1 per 100,000. Laparoscopic sleeve gastrectomy
(LSG) provides specimens of the majority of the stomach for review. Recent data suggest
this incidence may be higher in the morbidly obese population. The aim of this study was to
review pathology from our LSG specimens and identify the incidence of GIST and other
histopathologies at our institution.
Methods: A retrospective review of LSG cases at our institution was performed between
December 2013 to July 2015. Data obtained included age, gender, BMI, h. pylori serology,
co-morbid conditions (hypertension, diabetes, reflux disease), and histopathology report.
Results: Pathology reports of 265 LSG patients revealed incidental GIST in 5 patients
(2 %). The tumor sizes ranged from 0.3 to 2.5 cm, all with negative margins. The tumors
were located at the greater and lesser curve, fundus, and GE junction. H. pylori was
identified in 35 patients (13 %) and chronic gastritis in 92 patients (35 %). Neither h. pylori
nor gastritis were associated with GIST pathology.
Conclusions: Although GIST is reportedly rare in the general population, the incidence in
our cohort is much higher. This could be due to underdiagnosed lesions in the asymptomatic
person or a true association with obesity. More research should investigate this association.
The surgeon must recognize the increased incidence of GIST in the morbidly obese population and pay special attention to abnormal tissue encountered. LSG is a safe operation
for negative margin resection of incidentally found GIST.

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Validity Verification of Exoskeleton Surgical Assist Suit
by Suturing Swine Stomach
1

Kei Aoki, None , Hiroshi Kawahira , Ryota Nakajima , Yshihiro

Shimomura4, Hisahiro Matsubara5, 1Department of Medical System
Engineering, Chiba University, 2Center for Frontier Medical
Engineering, Chiba University, 3Graduates School of Medical
and Pharmaceutical Science, Chiba University, 4Division of Design
Science, Graduate School of Engineering, Chiba University,
5
Department of Frontier Surgery, Graduate School of Medicine,
Chiba University
Introduction: In the laparoscopic surgery, Trocar placement at the abdominal wall limits
surgeons forceps operation. Besides, it is necessary for the lap surgeons to twist a neck and
a body to watch a monitor during the surgery. Lap surgeons might have to keep painful
posture. Therefore, the physical burdens for lap surgeons were increased compared to the
traditional open surgeons. In order to reduce lap surgeons physical burdens, we developed
an exoskeleton assist suit (Surgical Assist Suits, SAS). The concept of the SAS is to hold
the surgeons upper arm and not to move automatically. We experimented for verify
validity of SAS in the dry box that simulated endscopic surgery environment.
Methods: In the dry box, the subject continuous sutured transection state swine stomach by
30 Polysorb. The subject was a surgeon. The experiment was conducted twice that he
didnt use SAS and three times used SAS. We measured anterior and side deltoid EMG: it
was relativized at maximum voluntary contraction amplitude (%MVC).
Results: According to the experimental results, we did unpaired t-test: every part %MVC
between with SAS and without SAS. From the result, we couldnt obtain significant difference between not use and use. Therefore, we couldnt confirm validity of SAS.
Conclusion: SAS was designed for holding upper arm elevation. For that reason, it was
suggested that SAS may not be effective at this experiment that continuous suture was the
main procedure. From the experimental results, we reconsider use of SAS and revisit
methods of validity verification, and report future prospect.

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Importance of Preoperative Weight Loss in Bariatric Surgery

Francisco Schlottmann, Marina Spano, Romina Reino, Martin
Galvarini, Jose Alvarez Gallesio, Rudolf Buxhoeveden, Hospital
Aleman of Buenos aires
Introduction: Due to the progress in bariatric surgery the number of complex patients who
undergo this procedure has increased. Multiple attempts have been made to determine risk
factors for postoperative complications. In this context, several authors stated that the
higher the preoperative weight loss, the lower the postoperative complication rate.
Therefore, many centers require a minimum 10 % weight loss before surgery. The aim of
this study was to evaluate the relationship between the percentage preoperative weight lost
and perioperative complications in bariatric surgery.
Methods and Procedures: A retrospective study based on a prospectively loaded database
was performed. A consecutive series of patients undergoing laparoscopic bariatric surgery
between 2008 and 2015 were included. The sample was divided into two groups according
to the percentage preoperative weight loss. G1: weight loss \10 % and G2: weight loss
[10 %. Surgical variables and early postoperative complications (\30 days) were evaluated in both groups.
Results: A total of 120 patients were included. Ninety-four patients belonged to G1
(78.3 %) and 26 patients to G2 (21.7 %). There were no significant differences in gender,
age, BMI and ASA score between groups. Gastric bypass and gastric sleeve were performed
in 85 % and 15 % in G1 and 73 % and 27 % in G2, respectively (p = NS). Length of stay
was 2.3 (25) days in G1 and 2.4 (24) days in G2 (p = NS). Clavien I-II complications
occurred in 16 patients in G1 (17 %) and in 7 patients in G2 (26 %) (p = NS). Clavien IIIIV complications were identified in three patients in G1 (3.2 %) and in none of the patients
in G2 (p = NS). There was no mortality in this series.
Conclusions: Although preoperative weight loss in bariatric surgery would be beneficial for
patients, no statistically significant difference was found between those with a decrease of
\10 % and those with a decrease greater than 10 %.

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Venous Thromboembolism After Laparoscopic Bariatric

Procedures: An Analysis of 1087 Patients at a Single Academic
Institution

Staple Line Reinforcements and Bleeding Rates in Laparoscopic

Gastric Sleeve Procedures: Are These Buttress Materials Worth
the Cost?

Luke Kinsinger, MD, Jessica Smith, MD, Peter Nau, MD, MS, Isaac
Samuel, MD, University of Iowa

Shoshana Hacker, MD, Eric Micallef, BS, Karleena Tuggle, MD,

Titus Duncan, Atlanta Medical Center

Background: While several steps forward in venous thromboembolism (VTE) in bariatric

procedures have been made, it continues to be the most common fatal complication in this
procedure.
Methods: In this study all laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve
gastrectomy, and laparoscopic gastric band insertion patients were retrospectively studied
from a prospectively collected cohort. The standard treatment regimen was preoperative
weight loss and daily exercise regimen, 5000 IU heparin was administered subcutaneously
preoperatively and then every 8 hours postoperatively, mechanical prophylaxis with
ambulation within 3 hours of arriving to the bariatric unit and bilateral calf sequential
compression devices during the procedure and while in the hospital.
Results: A total of 1087 patients underwent these procedures from January 2008 to
September 2015 by 4 different minimally invasive trained surgeons. 4 total VTEs occurred
with incidence of 0.37 %. 3 VTEs occurred in 818 laparoscopic Roux-en-Y gastric bypass
patients with incidence of 0.37 % (2 pulmonary emboli and 2 deep venous thromboses). 1
VTE occurred in 233 sleeve gastrectomy patients with incidence of 0.43 % (1 deep vein
thrombosis). No VTEs were seen in 36 laparoscopic adjustable gastric band insertions. No
mortalities were in this group of patients. None of the 4 patients had previous VTEs. 1
patient had a reoperation for leak and the pulmonary embolus was found 1 month post
operatively. 1 deep vein thrombosis was found postoperative day 5, and the other was found
3 months postoperatively. The final pulmonary embolus was found 2 months
postoperatively.
Conclusion: Maintaining high standards for patients in regard to preoperative weight loss
as well as appropriate preoperative exercise regimen and education for early ambulation can
reduce risk of VTE occurrence in bariatric procedures.

Introduction: Mechanical stapling devices are routinely used in bariatric surgery however
a well known complication is bleeding. Many buttress materials have been developed in an
effort to reduce bleeding. Peri-Strips Dry is a biological tissue derived from bovine pericardium that acts as a buttressing material to the staple line. It has been advocated as an
essential tool in bariatric surgery. However the data in regards to decreasing bleeding in the
gastric sleeve procedure with this product is still controversial.
Hypothesis: There is no significant difference of staple-line bleeding rates in laparoscopic
gastric sleeve procedure with the use of Peri-strips Dry versus no Peri-Strips Dry and
instead lowered pneumoperitoneum to better evaluate and treat staple-line integrity.
Methods: A retrospective analysis of 314 patients that underwent laparoscopic sleeve
gastrectomy between May 2014 to August 2015 at a bariatric center of excellence was
conducted. Cases were divided into two groups: with Peri-Strips Dry and without its use.
140 cases were performed with the use of Peri-Strips Dry and 171 cases were done without
its use. In the cases without the use of the Peri-Strip Dry; the pneumoperitoneum was
decreased to 10 mmhg after resection and the staple line was examined for any bleeding. If
bleeding occurred hemostasis was achieved by electrocautery or over sewing the stapleline. A staple line bleed was considered significant if it required a re-operation or blood
transfusion.
Results: Fewer staple-line bleeds were observed in the Peri-strip Dry group (1/140 [0.7 %]
vs. the no Peri Strip Dry group (4/171 [2.34 %]) however these findings were not significant
with a Z score of 1.1335 and a p- value of 0.258. For the patients in the no Peri-Strip Dry
group that had bleeding three required a re-operation and the other a blood transfusion.
There were no deaths in all the cases.
Conclusion: There was no significant difference of staple-line post operative bleeding rates
in laparoscopic gastric sleeve procedure with the use of Peri-strips Dry versus no Peri-Strips
Dry and instead lowered pneumoperitonueum to better evaluate and treat staple line
integrity. The additional cost to the laparoscopic gastric sleeve procedure due to the use of
Peri-Strips Dry is around $1500 per case. Therefore we must pose the question: if
hemostasis can adequately and safely be prevented without the use of buttress material then
is it worth the additional cost to the patient?

P432
Study of Gastroesophageal Reflux in Patients Submitted
Laparoscopic Sleeve Gastrectomy: Correlation Between
Symptoms and Nuclear Tests
Nelida Diaz, Juan Francisco Ruiz Rabelo, PhD, Elena Navarro
Rodriguez, MD, Luisa Mena, Juan Antonio Vallejo, Antonio
Membrives Obrero, Francisco Javier Briceno Delgado, Hospital
Universitario Reina Sofia
Introduction: Gastroesophageal reflux after sleeve gastrectomy is a controversial issue.
Sleeve gastrectomy has demonstrated great effectiveness. Nevetheless the posibility to
develop the novo gastroesophageal reflux disease (GERD) due to the impact on
esophagogastric union and its functionality is one of the major criticism of this technique.
The aim of this study is to analyze the correlation between GERD symptoms and the study
of gastroesophageal and bile reflux after sleeve gastrectomy.
Patients and Methods: 34 consecutive patients were included in this study. Inclusion
criteria were: age between 18 and 65 years old, BMI [ 40 kg/m2. It was discarded preoperative GERD or hiatal hernia by conducted interview, pHmetry, manometry and
endoscopy. Patients were submitted sleeve gastrectomy by the same surgery team. Watersoluble contrast esophagogastric transit was done between 48 and 72 hours post surgery. Six
months after surgery patients filled in GERD-Q and Rome III criteria questionaires, validated and adapted to be used in Spanish. After that they were performed a gastroesophageal
reflux scintigraphy and biliar Tc99 m-scintigraphy to evaluate both gastroesophageal and
bile reflux.
Results: Preoperative median BMI was 52,37 kg/m2 and mean age was 41,18 years old.
41,1 % of patients were man and 58,8 % were women. A 11,8 % of patients had GER in
scintigraphy, and another 5,9 % of them showed bile reflux at biliar Tc99 m scintigraphy..
In respect of gastrointestinal symptoms, 10 patients presented symptoms of GERD on the
GERD-Q. Regarding ROME-III criteria, 6 patients had functional heartburn criteria and 5
had functional dispepsia criteria.
All patients that showed gastroesophagueal reflux in the scintigraphy had also clinical
criteria for GERD on the GERD-Q (75 % had criteria for severe GERD and 25 % for
GERD), in addition the severity of the symptoms was related to the number of reflux
episodes during the examination. Respect ROME III criteria 1 (25 %) patient fulfilled
criteria for functional dispepsia and 3 of them (75 %) for functional heartburn criteria.
Patients that showed biliary reflux did not have gastrointestinal symptoms for any of the
diseases contained in ROME III criteria.
Conclusions: The integrity of the OG junction is a major factor for esophagitis and Barrets
esophagus. The correlation between GERD symptoms and follow-up testings may help us
detect those patients with reflux, in order to recommend endoscopy monitoring. Our study
showed good correlation between GERD symptoms and scintigraphy. Nevertheless we
found some cases of biliary reflux without symptoms, which are difficult to interpret.

P434
Low-Opioid Multimodal Pain Control Strategies Reduce Narcotic
Utilization in Sleeve Gastrectomy Patients
Kyle Kleppe, MD, Hien Le, MD, Gregory Mancini, MD, UT Medical
Center - Knoxville
Introduction: With the advent of enhanced recovery protocols, peri-operative multimodal
pain control methodologies have been employed increasingly in an effort to reduce opioid
use, improve post-operative pain control, and decrease length of stay. Our bariatric program
has adopted use of low-opioid multimodal therapies in an effort to accomplish these goals
in sleeve gastrectomy patients. Utilization of liposomal bupivacaine as intra-operative local
anesthetic as well as pre- and post-operative administration of intravenous acetaminophen
has allowed for us to transition from traditional use of patient controlled analgesia (PCA)
pumps. This study evaluates our sleeve gastrectomy population for significant effects from
instituting these strategies on analgesic use and length of stay.
Methods: A single institution, retrospective cohort study of 282 successive sleeve gastrectomy patients from 2010 to 2015 were selected from our bariatric database. Inclusion
criteria required single operation during hospital admission, no utilization of opioids preoperatively, and complete data for analysis. Patient data points analyzed included
intraoperative local anesthetic choice, IV acetaminophen use, and post-operative PCA use
on post-anesthesia care unit (PACU) time to floor readiness, PACU narcotic administration,
floor narcotic use, and floor length of stay. Nonparametric between subjects statistics were
used as our findings were not normally distributed.
Results: Significant reduction in PACU narcotic use was observed dependent on choice of
local anesthetic. Lidocaine 1 % / bupivicaine 0.25 % versus bupivacaine 0.25 % (median
PO morphine equivalents 10 vs 20 mg p \ .001) and liposomal bupivacaine versus bupivacaine 0.25 % (median PO morphine equivalents 16 vs 20 mg p = .01) demonstrated a
reduction. PACU time to readiness and narcotic consumption was not influenced by preoperative IV acetaminophen use. Post-operative PCA use resulted in significantly higher
floor narcotic consumption (76.5 mg vs. 23.5 mg PO morphine equivalents, p \ .001).
Increased floor narcotic use had a significant positive correlation with increased length of
stay (r = .31, p \ .001, r2 = .10).
Conclusion: A multimodal, opioid-sparing approach to perioperative analgesia, compared
to standard pain control methods utilizing PCA, contributes to reduced narcotic use in the
peri-operative period of sleeve gastrectomy patients and may lead to shorter hospital length
of stay. Narcotic related peri-operative complications have been well documented and
should be evaluated in further prospective studies.

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P435

P437

Perioperative Outcomes of Single-Stage Revision of Laparoscopic

Adjustable Gastric Band to Laparoscopic Sleeve Gastrectomy
Versus Laparoscopic Gastric Bypass

Preoperative Weight Change as a Predictor of Postoperative

Weight Loss Following Laparoscopic Sleeve Gastrectomy

Davis Waller1, Angel Farinas, MD2, Christian Cruz Pico, MD2,

Angelina Postoev, MD2, Christopher Ibikunle, MD2, Aliu Sanni,
MD2, 1MCG/UGA Medical Partnership, 2Georgia Surgicare
Introduction: Despite its appealing short-term outcomes and simplicity, laparoscopic
adjustable gastric banding (LAGB) requires revisional surgery in up to 30 % of patients due to
insufficient weight loss and associated complications. Considering the increasing usage of singlestage revisional laparoscopic sleeve gastrectomy (rLSG) as a revisional procedure, this review
evaluates whether it is a feasible alternative to revisional laparoscopic roux-en-y gastric bypass
(rLRYGB) in terms of perioperative clinical outcomes.
Methods: A systematic review was conducted using relevant studies at PubMed from 20102015
with comparative data on single-stage revision of LAGB to either rLSG or rLRYGB. The primary
outcomes were percentage of estimated weight loss (%EWL) at 12 months, operative time (min.),
hospital stay (days), mean complications, reoperations and intraoperative blood loss. Results are
expressed as standard difference in means with standard error. Statistical analysis was done using
random-effects meta-analysis to compare the mean value of the two groups (Comprehensive Meta
Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).
Results: Three retrospective studies were quantitatively assessed and included for meta-analysis.
Among the three studies, 134 were rLSG and 124 were rLRYGB. There was an increased operative
time (-0.521 0.259, p = 0.0), length of stay (-0.341 0.258, p = 0.009), and operative blood
loss (-0.381 0.333, p = 0.025) in the rLRYGB group when compared to the rLSG patients. %EWL at 12 months (-0.285 0.34, p = 0.102), post-operative complications
(-0.309 0.326, p = 0.063), and reoperations (-0.221 0.292, p = 0.136) were similar in both
groups.
Conclusions: Single-stage rLSG presents similar outcomes to rLRYGB for LAGB revisional
bariatric surgery. It is associated with reduced operative time, length of stay, and blood loss.

Vanessa Falk, MD, David Pace, MD, FRCSC, Simon Tewes, MD,
Felicia Pickard, MD, Brad Evans, MD, Raleen Murphy, Deborah
Gregory, PhD, Laurie Twells, PhD, Memorial University
of Newfoundland
Introduction: At our bariatric surgery center, patients are required perform food journaling and a
trial of liquid diet for two weeks prior to their bariatric procedure. They are encouraged to lose
weight, however, this does not impact their eligibility for surgery. The purpose of this study is to
determine if preoperative weight gain affects postoperative weight loss following laparoscopic
sleeve gastrectomy (LSG).
Methods: This is a retrospective chart review of patients who underwent LSG at a single bariatric
center from May 2011 to February 2014. Data on patient demographics, preoperative weight
change, postoperative weight loss at 6 and 12 months, comorbidities, and postoperative complications were collected. Two groups of patients were compared, those who gained weight in the
preoperative period and those who either maintained or lost weight during this period. Paired
Student t-tests and independent Student t-tests were used to compare continuous variables and Chisquared analysis was used for categorical variables. Statistical analysis was performed using SPSS
(Version 21).
Results: One hundred and eighty seven patients underwent LSG (n = 187). There were 77 patients
who gained weight and 110 patients who maintained or lost weight prior to LSG. There was no
difference in mean age (44 years), gender ([80 % female), preoperative weight (135 kg), preoperative body mass index (49.2 kg/m2), or obesity associated comorbidities between groups. There
was a significant difference in mean weight loss at 6 months (26.3 8.5 kg vs. 32.3 9.9 kg,
p \ 0.001) favoring the group that maintained or lost weight prior to surgery but no difference in
mean weight loss at 12 months was noted (36.5 13.9 kg vs. 38.7 14.2 kg, p = 0.381).
Similarly, there was no difference in %estimated BMI loss between groups at 12 months
(56.6 16.4 %kg/m2 vs. 61.9 18.4 %kg/m2, p = 0.744). There was no difference in the overall
30-day postoperative complication rate between groups (13 % vs. 20 %, p = 0.241).
Conclusion: Preoperative weight gain does not predict postoperative weight loss following
laparoscopic sleeve gastrectomy at 12 months.

P436

P438

Role of Bariatric Surgery on Morbid Obesity in Polycystic

Ovarian Syndrome

Weight Loss and Obesity Co-morbidity Outcomes Vary by Race

After Open Roux-en-Y Gastric Bypass (ORYGB): Analysis
of 5389 Bold Database Patients

Ashish Ahuja, MS, Dayanand Medical college&hospital

Introduction: Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder
among women of reproductive age.Pcos encompasses a broad spectrum of signs&symptoms of
ovary dysfunction, obesity, blood pressure, insulin resistance & infertility. Bariatric Surgery can be
an effective means of weightloss in Pcos & curing Infertility .
Materials and Methods: 15 female patients were enrolled in the study from 20122014.66 %(n = 5)
Were in age group of 2030 years, 33 %(n = 8) were in age group of 2533 years who underwentBariatric surgery in form of Laproscopic sleeve Gastrectomy (LSG)& Roux-en-Y gastric
bypass.LSG 73 %(n = 10), RYGB26 %(n = 4)
Results: There was a significant improvement in obesity (60 % excess weight loss) over 1 year
after bariatric surgery, in 12 patients there was gross improvement in restoration of menstrual cycle
who had irregular menstrual cycle. In 80 % patients the serum insulin level showed normal value.
Over two years 8 patients become pregnant.
Conclusion:
1. Obese women with Pcos maybe able to conceive after Bariatric Surgery.
2. Women with Pcos should only consider bariatric surgery if they were already considering it for
other reasons to treat obesity, blood pressure & other co-morbid conditions .
Keywords: Polycystic ovarian Syndrome (PCOS); LSG (Laproscopic Sleeve Gastrectomy; RYGB
Roux-en-Y; Gastric bypass.

Amna Mehdi, DO, Gus Slotman, MD, Inspira Health Network

Objective/Background: Today, ORYGB is chosen primarily for massively obese patients and for
those with complex intra-abdominal scarring/anatomy. In managing these fragile patients, every
clinical insight helps. While pre-operative characteristics of ORYGB patients differ among racial
groups, whether or not post-ORYGB outcomes are affected by race is unknown. The objective of
this study was to identify outcomes variation in weight loss and obesity co-morbidities following
ORYGB by racial groups.
Methods and Procedures: Data from the Surgical Review Corporations BOLD database on 5,389
patients who underwent open Roux-en-Y gastric bypass (ORYGB) was analyzed retrospectively in
four groups over 24 months postoperatively: African-American (n = 503), Caucasian (n = 3769),
Hispanic (n = 460), and Other (Pacific Islands, Native American, or [1 race recorded; n = 652).
Five Asian patients were too few to analyze. Outcomes analysis used General Linear Models that
included baseline and post-operative data, and were modified for binomial distribution of
dichotomous variables.
Results: Angina, CHF, peripheral vascular disease, pulmonary hypertension, obstructive sleep
apnea, obesity hypoventilation syndrome, asthma, abdominal hernia, stress urinary incontinence,
gout, PCOS, pseudotumor cerebri, leg edema, mental health diagnoses and alcohol/tobacco/substance abuse did not vary by race.

Conclusions: Many clinically important outcomes following ORYGB vary by race. It is important
for surgeons to recognize significant variations in postoperative results for morbidly obese patients
based on their race, which advance knowledge can impact how patients respond to ORYGB.
Understanding differential responses by race classification in weight loss and in the resolution of
weight-related medical problems can help physicians optimize post-ORYGB medical care.

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P441

Laparoscopic Sleeve Gastrectomy Among Morbidly Obese

Adolescents

A Case Series of Candy Cane Syndrome: An Underappreciated

Cause of Abdominal Pain and Nausea After Roux-en-Y Gastric
Bypass Surgery

Aslam Ejaz, MD, Robert Kanard, MD, Pankti Patel, MD, Raquel
Gonzalez-Heredia, Md, PhD, Pablo Quadri, MD, Lisa SanchezJohnsen, PhD, Enrique Elli, MD, UIC
Background: The increasing prevalence of obesity has led to an increase in the use of
bariatric surgery in the adolescent population. However, outcomes following laparoscopic
sleeve gastrectomy (LSG) among adolescents have not been well-studied. The aim of this
study was to examine %excess weight loss and perioperative and postoperative outcomes
following LSG in patients under 21 years of age.
Methods: All patients who underwent LSG as a primary surgical option for morbid obesity
were identified at our institution between January 2006 and December 2014. Patient
demographics, pre-surgical comorbidities, perioperative outcomes, post-operative complications, operating time, length of hospitalization, and percent excess weight loss (%EWL)
were recorded.
Results: Eighteen patients (13 females, 5 males) underwent LSG. Mean patient age was
17.8 1.7 years. Mean BMI among all patients was 48.6 7.2 kg/m2 and did not differ
by sex (p = 0.68). Median length of hospitalization following LSG was 3 days (IQR: 2, 3).
One patient (5.6 %) experienced a 30-day perioperative complication (pulmonary embolism). Two patients (11.1 %) were readmitted within 30 days due to feeding intolerance
that resolved without invasive intervention. At a median follow-up of 9.5 (range: 038)
months, percent excess weight loss (%EWL) among all patients was 34.1 %. Among
patients with at least 2 years follow-up (n = 3), %EWL was 50.2 %.
Conclusions: This initial data suggests that among adolescents, LSG was associated with a
34.1 % EWL at a median follow-up of 9.5 months. Future studies with larger samples of
adolescent patients as well as a longer follow-up period post LSG are warranted.

P440
The Effect of Calibration Device Choice on Sleeve Gastrectomy
Pouch Creation and Subsequent Weight Loss
Christopher Guidry, MD, Obos Ekhaese, DO, University of Texas
Medical Branch
Background: Controversy exists amongst expert sleeve gastrectomy surgeons on the ideal
technique for the creation of gastric pouch. There are many technical variations on the
creation of a gastric sleeve including the type of calibration device used, use of varying
sizes of bougie dilators, or employing a gastroscope as a bougie. This study investigates
compares two technical variations to the gastric sleeve creation (bougie dilator vs. gastroscope as bougie) to determine if an appreciable difference in excess body weight loss
occurs.
Methods: We performed a retrospective chart review of the first 100 patients who
underwent a laparoscopic or robotic sleeve gastrectomy from March 2010 to August 2014.
The techniques used for the creation of the gastric sleeve were examined. Teleflex Maloney
esophageal dilator bougie that ranged in size from 36F to 42F and video gastroscope with
an 11 mm diameter/33F were the calibration devices used in all but 2 of the cases, in which
the Visigi-3D 40F calibration device was utilized. Each patients pre-operative weight,
BMI, ideal body weight (IBW) and excess body weight (EBW) were examined prior to
operation. Each patients excess weight loss percentage (EWL %) were recorded during
follow-up clinic visits at 1 month, 3 month, 6 month, 1 year intervals.
Results: The Maloney bougie dilator was used in 73 patients and the gastroscope + Visigi
as a bougie / calibration was used in 27 patients. The average pre-operative BMI for the
Maloney dilator and gastroscope groups were 42.6 kg/m2 and 41.4 kg/m2, respectively.
Average EWL % with the Maloney dilator was 19 %, 30 %, 36 % and 38 % at 1 month,
3 months, 6 months and 1 year respectively. Average EWL % with the gastroscope as a
bougie was 19.1 %, 33.6 %, 44 % and 59 % at 1 month, 3 months, 6 months and 1 year
respectively.
Conclusions: There is an appreciable difference in weight loss in patients whom had gastric
sleeves created via the gastroscope as a bougie at 6 months and 1-year intervals compared
to the utilization of an esophageal dilator as a bougie. These findings may have been due to
the suction component of the gastroscope, as well as the uniform diameter and its blunt end
versus a tapered Maloney bougie dilator, which allows for a more precise sleeve creation by
improving visualization and contour of the gastric sleeve. Future studies will focus on
increasing the number of endoscopic bougie cases and follow both patient groups at 2 year
and 3 year intervals.

Amir H Aryaie, MD, Mojtaba Fayezizadeh, MD, Mujjahid Abbas,

Leena Khaitan, MD, University Hospitals Case Medical Center
Introduction: Candy Cane syndrome (a blind afferent Roux limb at the gastro-jejunostomy [GJ]) has been implicated as a cause of abdominal pain, nausea, and emesis after
Roux-en-Y gastric bypass procedure (RYGB), but remains poorly described. This case
series demonstrates that candy cane syndrome is real and can be treated effectively with
revisional bariatric surgery.
Methods: A prospective database was used to identify all patients who underwent revisional bariatric surgery for candy cane between January, 2011, and July, 2015. All had
pre-operative work up including upper gastro-intestinal series (UGI), upper endoscopy, and
detailed history. Demographic data, peri-operative symptoms, data regarding the hospitalization and post-operative weight loss were assessed through retrospective chart review.
All those noted to have a combination of abdominal pain, emesis and/or nausea in the
setting of an elongated afferent limb identified on endoscopy and UGI were taken for
revision of the candy cane. Proper dietary habits were confirmed prior to revision. Data
maintained in excel database and analyzed using students T-test.
Results: Nineteen patients had resection of the candy cane (95 % female, mean age
50 11), within 311 years after initial RYGB. Presenting symptoms were epigastric
abdominal pain (68 %) and nausea/vomiting (42 %), particularly with fibrous foods and
meats. On UGI, the afferent limb appeared to fill first before spilling into the roux limb.
On endoscopy, the afferent limb was the most direct outlet from the gastro-jejunostomy.
Eighteen (94.7 %) cases were completed laparoscopically (mean operative time 106 minutes (range 54206). All patients had intra-operative endoscopy to ensure patency of the
gastro-jejunostomy whilst removing the candy cane. Length of candy cane ranged from
322 cm (mean = 7.6). Median length of stay was 1 day (range 116). After resection, 18
(94.7 %) patients had complete resolution of their symptoms (p \ 0.001). Mean BMI
decreased from 33.9 (range 2645) pre-operatively to 31.7 (range 2542), at 6 months
(17.4 % EWL), and 30.5 (range 2241) at 1 year (25.7 % EWL). There were no complications or readmissions.
Conclusion: Candy Cane syndrome is a real phenomenon that resolves after resection of
the blind afferent limb. A thorough diagnostic work up is paramount to proper identification
of this syndrome. This syndrome can be managed safely with excellent outcomes with
revisional surgery and removal of the afferent limb. Based on these data, surgeons should
consider minimizing the size of the blind afferent loop left at the time of initial RYGB.

P442
Increased Visceral Adiposity Fails to Predict Postoperative
Complications in Roux-En-y Gastric Bypass Patients
Salvatore Docimo, Joshua S Winder, Brandon S Dudeck, Brandon
Labarge, Ann M Rogers, Penn State Hershey Medical Center
Introduction: Worse surgical outcomes in obese patients may be explained by a systemic
pro-inflammatory response; adipose tissue releases inflammatory mediators, including
tumor necrosis factor-a, interleukin-6, and leptin [35]. Quantitative analysis of visceral
adiposity using computerized tomographic (CT)-based measurements has been evaluated as
an effective means of assessing obesity in patients [67]. Our objective was to introduce a
quantitative measure to study the effect of visceral obesity on post-operative morbidity and
mortality in patients undergoing Roux-en-y gastric bypass (RYGB).
Methods: A retrospective review of patients undergoing RYGB from 20062013 was
performed with institutional review board approval. All patients who underwent CT of the
abdomen within 30 days postoperatively were included. Patient demographics, CT findings,
length of stay (LOS) and complications were evaluated. Preoperative body mass index
(BMI) was calculated. Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM (2015) viewer software. Visceral fat areas (VFA)
and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4L5 intervertebral space. The CT attenuation level to delineate the regions of adipose tissue
was set using Hounsfield units of -190 to -30 [11]. The VFA and SFA were then measured. The VFA to SFA ratio (V/S) was calculated. The currently defined obesity threshold
is V/S C 0.4 [11,12]. Statistical analysis was performed utilizing Chi-square and Students
T-test evaluations.
Results: 51 patients were evaluated. Twenty-six had a V/S \ 0.4 (average V/S ratio 0.27)
and 25 had a V/S ratio[0.4 (average V/S ratio 0.56; p = 0.0001). For the V/S \ 0.4 group,
the average age and BMI were 42.5 years, 42.98 kg/m2, with 5 (19.2 %) males, and 21
(80.8 %) females. For the V/S [ 0.4 group, the average age and BMI were 49.96 years and
44.58 kg/m2, with 11 (44 %) males and 14 (56 %) females. The difference in age was
significant (p = 0.0094). No significant differences in the postoperative complications
(p = 0328), LOS (p = 0.388), or number of surgical interventions (p = 0.679) were noted.
Conclusions: Evaluation of visceral adiposity among bariatric patients undergoing postoperative CT scans failed to demonstrate a statistically significant difference in
complication rate, length of stay or rate of surgical intervention. Given the current safety of
laparoscopic bariatric surgery, visceral fat alone is an unlikely marker for increased complications in bariatric patients.

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P445

The Use of Predictive Markers for the Development of a Model

to Predict Lowest Quartile Weight Loss Following Roux-en-Y
Gastric Bypass

Comparison of Estimated Weight Loose in Sleeve Gastrectomy

and Roux-en-Y Gastric By-Pass

Samuel Cottam, Austin Cottam, Daniel Cottam, MD, Amit K Surve,

MD, Hinali Zaveri, MD, Christina Richards, Bariatric Medicine
Institute
Background: The Roux-en-Y Gastric Bypass (RYGB) has been one of the most popular
surgeries in the USA for years. While many models have been made to investigate the
factors that affect weight loss, these factors are still highly debated.
Objective: To use multivariate analysis to investigate the factors that predicts performance
of RYGB patients.
Setting: Private Practice, United States
Methods: 110 out of 344 patients who received a RYGB at a single institution between Jan
2010 and April 2014 were included in this study. Data was collected retrospectively.
Patients were included if they had greater than 1 year follow up with at least three follow up
points and could be modeled with R2 [ 0.95. All patients were one year beyond surgery,
while 40 were completely lost to follow up, 104 at 1 month, 138 at 3 months, 188 at
6 months, and 225 at one year. 9 patients were not included because they did meet the
criteria of the study. Patients were divided into quartiles based on percentage excess weight
loss (%EWL) at one year. Multivariate analysis was performed to determine the significant
factors that influence patients being in the first quartile of weight loss (1760 % %EWL).
Results: Only males with a Body Mass Index (BMI) above 44 and females with a BMI
above 64 were found to be predictive of patients being in the first quartile. Our model has
Positive and Negative predictor values of 66 % and 80 % respectively with sensitivity and
specificity of 29 % and 95 % respectively.
Conclusions: Due to the lack of weight loss male patients with a BMI over 44 and female
patients with a BMI over 64 will most likely end up in the bottom quartile. This information
should be discussed with patients when deciding a procedure.

P444
A Va-Based Multidisciplinary Clinic Improves Follow-Up After
Bariatric Surgery
Nalani Grace, MD, Eric Kubat, MD, Dan Eisenberg, MD, MS, VA
Palo Alto
Introduction: Outpatient follow-up after bariatric surgery is associated with improved
outcomes and patient satisfaction. At our Veterans Affairs Medical Center (VAMC) we
have established a unique multidisciplinary clinic. We sought to examine whether 1-year
postoperative follow-up would increase as a result.
Methods: A retrospective review of a prospective database of patients who underwent
gastric bypass or sleeve gastrectomy between 2003 and August 2014. A multidisciplinary
clinic which includes a patient assessment by a surgeon, bariatrician, dietitian, physical
therapist, and psychologist at each visit, was established at our VAMC in 2008. Significant
differences were determined using a t-test.
Results: Of 221 patients who underwent bariatric surgery at our VAMC, 97 (44 %) were
followed before institution of a multidisciplinary clinic (PRE), and 124 (56 %) were followed after institution of a multidisciplinary clinic (POST). Most were male (78 %), and
mean pre-operative BMI was similar in both groups (47 kg/m2 and 46 kg/m2, respectively).
The rate of follow-up at 1 year after surgery was significantly higher in the POST group,
compared to the PRE group (85 % and 76 %, respectively; p = 0.037). Despite the fact that
most patients in the PRE group underwent gastric bypass (96 %), while most patients in the
POST group underwent sleeve gastrectomy (88 %), the remission of diabetes (66 % vs.
69 %, p = 0.86) and remission of hypertension (42 % vs. 47 %, p = 0.55) were similar in
both groups. The decrease in BMI experienced in the first post-operative year was higher in
the PRE compared with the POST group (DBMI = 14 vs. 11 kg/m2, respectively,
p \ 0.01).
Conclusion: A dedicated multidisciplinary weight loss clinic leads to better short-term
follow-up after bariatric surgery. As the proportion of sleeve gastrectomy operations
increases in the veteran population, a VA-based multidisciplinary clinic may prove effective in maintaining postoperative outcomes similar to gastric bypass.

123

Mehmet Mihmanli, Prof, Riza Gurhan Isil, PhD, Ufuk Oguz Idiz,
PhD, Uygar Demir, PhD, Cemal Kaya, PhD, Canan Tulay Isil, PhD,
Pinar Sayin, PhD, Yuksel Altuntas, Prof, Hamidiye Sisli Etfal E.A.H.
Objectives: Estimated weight loose (EWL) is an important parameter in bariatric surgery
indicating the postoperative success in weight loss. We aimed to compare the EWL in
sleeve gastrectomy and roux-en-y gastric by-pass.
Materials and Methods: During a one-year period (2013) data of patients who underwent
bariatric surgery in our clinic were recorded prospectively including demographical data,
operation type, preoperative Body Mass Index (BMI) and postoperative 1st-3rd-6th and
12th month BMI. The patients were analyzed in two groups; GroupS (n = 30): patients
who underwent sleeve gastrectomy and GroupR (n = 30): patients who underwent RouxEn-Y Gastric By-Pass.
Results: There was no statistically significant difference regarding the patients demographics and perioperative complication rates. Body Mass Index (BMI) was 51,3 +/-8,5 in
GroupS and 56,1 +/-7,3 (p = 0.024).
Conclusion: Albeit Roux-En-Y Gastric By-Pass is a more invasive procedure compared to
sleeve gastrectomy and has its own handicaps related to the operational procedure, this
study indicated that Roux-En-Y Gastric By-Pass is more successfull in EWL compared to
sleeve gastrectomy. However, sleeve gastrectomy is a more simple procedure compared to
Roux-En-Y Gastric By-Pass and with mean 80,9 % EWL sleeve gastrectomy can be
choosen alternatively to Roux-En-Y Gastric By-Pass, which has a 89,2 % EWL.

P446
Perioperative Outcomes of Laparoscopic Sleeve Gastrectomy
Versus Laparoscopic Roux-en-Y Gastric Bypass
in the Superobese Population
Davis Waller1, Angel Farinas, MD2, Christian Cruz Pico, MD2,
Angelina Postoev, MD2, Christopher Ibikunle, MD2, Aliu Sanni,
MD2, 1MCG/UGA Medical Partnership, 2Georgia Surgicare
Introduction: Among patients undergoing bariatric surgery, the superobese patients
(BMI [ 50) are considered more challenging with higher morbidity and mortality. Few
studies have been published regarding perioperative outcomes of bariatric surgery in this
particular patient group, and even fewer studies offer a direct comparison of clinical outcomes between the traditional laparoscopic Roux-en-y gastric bypass (LRYGB) and
laparoscopic sleeve gastrectomy (LSG). Considering the increasing use of LSG in this
patient population, a meta-analysis of the existing comparative data is useful for determining the appropriate procedural choice.
Methods: A systematic review was conducted to identify relevant studies from PubMed
from 20102015 with comparative data on perioperative outcomes of LRYGB versus LSG
in patients with BMI [ 50. The primary outcomes were percentage excess weight loss
(%EWL) at 12 months, operative time, length of stay, perioperative complications, and
mortality. Results are expressed as standard difference in means with standard error. Statistical analysis was done using random-effects meta-analysis to compare the mean value of
the two groups (Comprehensive Meta Analysis Version 3.3.070 software; Biostat Inc.,
Englewood, NJ).
Results: Four retrospective studies were quantitatively assessed and included for metaanalysis. Among the four studies, 238 were LSG patients and 422 were LRYGB patients.
LSG results in a significantly lower %EWL (-0.576 0.234, p = 0.01) and decreased
operative time (-0.590 0.176, p = 0.02) when compared to LRYGB. There were no
difference in the length of stay (-0.206 0.211, p = 0.055), rate of complications
(0.056 0.21, p = 0.599), or mortality (-0.002 0.255, p = 0.990) when comparing
these two procedures.
Conclusions: LSG is safe in the superobese patients as it presents similar outcomes to
LRYGB. The %EWL seen at 12 months is increased in the LRYGB group.

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P448

Development of Consensus-Derived Quality Indicators FOR

Bariatric Surgery

Outcomes of Bariatric Surgery for Japanese Patients

Shannon E Stogryn, MBBS, Krista Hardy, MSc, MD, FRCSC, FACS,

Jason Park, MEd, MD, FRCSC, FACS, Ashley Vergis, MEd, MD,
FRCSC, FACS, University of Manitoba
Introduction: Our objective was to systematically develop a list of operative report quality
indicators for laparoscopic Roux en Y gastric bypass (RYGB) surgery in order to generate
validated parameters by which operative documentation for RYGB surgery can be evaluated and improved.
Methods and Procedures: A Delphi protocol was used to determine quality indicators for
RYGB reporting. Canadian community and academic bariatric surgeons were recruited
along with local physician key stakeholders to participate via a secure web-based platform.
We aimed to have one representative bariatric surgeon from all regions in Canada currently
performing RYGB. Participants initially submitted potential quality indicators for a RYGB.
These indicators were assessed and grouped by theme. Items were then rated on a 9-point
Likert scale in subsequent rounds. For consensus, a score of 70 % (mean score 6.3) or
greater indicated inclusion of an item and 30 % (mean score 2.7) or less denoted exclusion.
Elements ranging from 30 - 70 % consensus were re-circulated by runoff in subsequent
rounds to generate the final list of quality indicators.
Results: Four community and four academic bariatric surgeons were invited to participate.
We achieved our goal of representation from all provinces performing RYGB in Canada.
The 4 local multidisciplinary invitees were comprised of: 1 academic minimally invasive/
acute care surgeon, 1 tertiary abdominal radiologist, 1 academic gastroenterologist with
expertise in advanced endoscopic techniques, and 1 general surgeon with expertise in
synoptic reporting. The initial survey achieved an 83.3 % (10/12) response and identified 91
potential quality indicators for consideration. The subsequent survey had a 100 % (12/12)
response rate. 69 items reached inclusion consensus (Table 1).
Conclusion: This study has established consensus-derived multidisciplinary quality indicators for RYGB operative reports. This information will allow further assessment of the
quality of existing documentation and will afford the development of a synoptic report that
may ameliorate any deficiencies identified.

Table 1 Quality Indicators for RYGB

Headings

#
Consensus Example of items
items

Team demographics

10
11

Pre-operative diagnosis

Intra-operative details

18

Roux length

Gastrojejunostomy
details

10

Background and Aim: Bariatric surgery has done widely in the world and the dramatic
effect is reported. However, the number is still less in our country. In our institute, bariatric
surgery was introduced in October, 2010, and twenty-four cases have undergone the surgery. The procedures were laparoscopic sleeve gastrctomy (LSG) and laparoscopic sleeve
gastrectomy with duodenal-jejunal bypasss (LSG/DJB). We investigated outcomes of
bariatric surgery in our institution retrospectively.
Patients and Method: Twenty-four patients who undergo bariatric surgery in our hospital
from 2010 to 2014 are included in this study. We measured and investigated the patients
body weight, body mass index (BMI), percent of excess body weight loss (ExBWL %),
status of metabolic diseases, operation time, blood loss, post operative length of stay and
postoperative complications. The data was shown as LSG : LSG/DJB below. All data was
examined by using median value.
Result: Twenty-four patients (M:F = 11:13) underwent bariatric surgery. Eighteen patients
underwent LSG, and six patients underwent LSG/DJB. The median age was 38.5 (2362):
38 (3058). Pre-operative body weight was 112.9 kg (94.2161.9): 108.7 kg (92170), and
BMI was 42.1 (32.657.5): 36.4 (35.054.3) respectively. The number of patients with
diabetes was 11 cases : 6 cases, and the median HbA1C level was 6.1 % (4.911.1) : 6.6 %
(6.211.8). The operation time was 139.5 min (99224): 271.5 min (257296), and blood
loss was 10 g (230): 45 g (10150). Post operative length of stay was 9 days (515):
10 days (817). ExBWL % was 53.3 % (-2.5 to 82.2): 53.8 % (28.567.2) one year after
surgery, and 34.8 % (-10.7 to 89.8) : 56.1 % (38.173.1) two years after surgery. HbA1C
level was 5.6 % (4.76.4): 5.9 % (5.09.0) one year after surgery, and 5.7 % (4.87.1):
5.5 % (4.98.7) two years after surgery. In fourteen cases (82 %), diabetes went into
remission. Especially, the remission occurred in five cases of LSG/DJB (82 %). Post
operative complications occurred only in two cases, and both of them were grade2 (fever
and intraluminal bleeding) according to Clavien-Dindo classification.
Conclusion: Bariatric surgery in our institution was effective and performed safely. In
particular, the effect of improving diabetes was higher in procedure of LSG/DJB.

Surgeon

Patient demographics
Enteroenterostomy
details

Hirofumi Imoto, MD, PhD, Takeshi Naitoh, MD, PhD, FACS, Naoki
Tanaka, MD, PhD, Munenori Nagao, MD, PhD, Kazuhiro Watanabe,
MD, PhD, Tomoya Abe, MD, PhD, Shinobu Ohnuma, MD, PhD,
Katsuyoshi Kudo, MD, PhD, Takeshi Aoki, MD, PhD, Hiedaki
Karasawa, MD, PhD, Takahiro Tsuchiya, MD, PhD, Fuyuhiko Motoi,
MD, PhD, Michiaki Unno, MD, PhD, Tohoku University Graduate
School of Medicine, Department of Surgery

Stapler # of firings
Pouch length

Closure details

Petersons space
closure

Post-operative details

Estimated blood loss

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P452

Incidental Pathological Findings Detected in Sleeve Gastrectomy

Specimens

The Impact of Enhanced Recovery Protocol for Patients

Undergoing Bariatric Laparoscopic Roux-en-Y Gastric Bypass

Baris D Yildiz, MD, Ankara Numune Teaching Hospital

Katie Meister, MD, Katelyn Mellion, MD, Anna Uebele, MD, Lala
Hussain, Kevin Tymitz, MD, George Kerlakian, MD, Good Samaritan
Hospital

Introduction: Sleeve gastrectomy is a popular surgical technique for the treatment of

obesity. There are different approaches for the preoperative work up of patients undergoing
sleeve gastrectomy when the neccessity of preoperative upper endoscopy is considered.
Methods and Patients: We retrospectively evaluated pathological specimens of 85 patients
who had sleeve gastrectomy between 2011 and 2015 performed by the same surgeon.
Demographical data, histological findings, pathological findings, postoperative complications were gathered for analysis.
Results: There were 2 cases with gastrointestinal stromal tumor detected in surgical
specimens. The rate of Helicobacter pylori was 70 %. One specimen contained an active
ulcer. This patient had a major postoperative leak which resulted in prolonged hospital stay
and eventually total gastrectomy. There was not any adenocancer pathology detected in
specimens.
Conclusions: Low rate of accompanying pathologies in our patient group might argue
against routine preoperative endoscopy for patients planned to undergo sleeve gastrectomy.
But additional studies should be done to reach a concluison about preoperative endoscopy
when other conditions such as hiatal hernia or reflux are considered. It might be worthwhile
testing our patient population for Helicobacter pylori preoperatively for probable treatment
planning. If preoperative endoscopy shows an active ulcer it might be wise to treat the ulcer
before the surgery.

Introduction: Enhanced recovery protocols (ERP) standardize perioperative patient care in an

effort to hasten recovery by minimizing the stress response of surgery, improving pain control,
accelerating gastrointestinal function, and minimizing hospital length of stay (LOS). This study
aims to evaluate the outcome of implementing an ERP for bariatric patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB).
Methods and Procedures: Our ERP was created to address the specific needs of morbidly obese
patients undergoing foregut surgery. Specific modalities include: extensive preoperative patient
education, regimented oral hydration until 3 hours preoperatively, multimodal pain management
(pregabalin and celecoxib preoperatively, narcotic and non-narcotic analgesia postoperatively),
judicious use of perioperative intravenous fluids, and early Foley catheter removal, ambulation, and
enteral feeding. This retrospective study examines outcomes of bariatric RYGB specific ERP from
January 2013 through June 2015. Exclusion criteria include patients who underwent RYGB for
reasons other than weight loss, whose procedure was abandoned, or who concomitantly underwent
another procedure. Demographic data include: age, gender, preoperative body mass index (BMI),
preoperative comorbidities, American Society of Anesthesiologists (ASA) class. Outcome variables include: LOS, 30-day readmission, 30-day reoperation, 30-day ICU admission. The effect of
preoperative comorbidities on patient LOS and 30-day readmission were assessed using Mann
Whitney U test and Chi-square or Fishers Exact tests, respectively. The 30-day readmission rate
was compared between patients before and after ERP implementation with Chi-square test.
P \ 0.05 was deemed statistically significant.
Results: A total of 88 patients were analyzed. Average age and preoperative BMI were 46.9 (11.6)
years and 47.8 (7.25) kg/m2, respectively. The cohort was 27.3 % male. Preoperative comorbidities
included: diabetes (48.9 %), hypertension (59.1 %), history of pulmonary embolism (5.7 %),
cardiovascular disease (CVD) (6.8 %), chronic obstructive pulmonary disease (3.4 %), gastroesophageal reflux (33.0 %), tobacco use (11.4 %), severe limitation to ambulation (3.4 %). The
ASA classes of patients undergoing RYGB were II (2.3 %), III (87.5 %), and IV (10.2 %). Average
LOS, 30-day readmission, 30-day reoperation, and 30-day ICU admission were 2.34 days, 13.6 %,
0 %, and 0 %, respectively. Patients with CVD were more likely to be readmitted within 30 days
(p = 0.031). Average LOS for patients with preoperative tobacco use was 2.47 days versus
1.30 days for those who did not (p = 0.002).
Conclusion: We have reported outcomes of using an ERP specific to bariatric patients undergoing
RYGB. Patients with preoperative tobacco use had a longer LOS, while those with CVD were more
likely to be readmitted. Future studies are needed to compare outcomes between non-ERP and ERP
populations.

P451
SAFETY OF PREOPERATIVE VLCD DIET AND BODY
COMPOSITION CHANGES AFTER BARIATRIC SURGERY
Takeshi Naitoh, MD, PhD, FACS, N Tanaka, MD, PhD, H Imoto,
MD, PhD, M Nagao, MD, PhD, K Watanabe, MD, PhD, T Abe, MD,
PhD, S Ohnuma, MD, PhD, K Kudo, MD, PhD, T Aoki, MD, PhD, H
Karasawa, MD, PhD, T Tsuchiya, MD, F Motoi, MD, PhD, M Unno,
MD, PhD, Tohoku University Graduate School of Medicine
Backgrounds: Bariatric surgery is known to improve obesity-related comorbidities and reduce the
mortality risk. Patients willing to have this surgery are morbidly obese with their BMI is over 35,
and most of patients have severe metabolic disorders such as diabetes mellitus or hyperlipidemia.
Therefore, preoperative diet therapy with very low calorie diet (VLCD) is considered as useful to
reduce operative morbidities. However, excessive diet therapy may lead to unexpected muscle
protein decomposition, and might increase the risk of complications.
Aim: We measured the body composition changes pre and postoperative periods using the
impedance body composition analyzer, and assess the safety of the preoperative VLCD diet.
Patients and Methods: Patients who underwent the bariatric surgery in our institute during 2010
and 2014 are included in this study. The body composition was measured with the impedance body
composition analyzer at the time of first visit, before surgery, 1, 3, 6 and 12 months after surgery.
Patients whose BMI is over 60 are asked to have complete VLCD diet in which intake calorie is
approximately 500 kcal/day until their BMI came down to less than 60. All eligible patients are
asked to have combination VLCD diet in which intake calorie is 1200 kcal/day for 4 weeks before
surgery. Surgical procedures were Laparoscopic sleeve gastrectomy (LSG) or Laparoscopic sleeve
gastrectomy with duodenal jejunal bypass (LSG/DJB). Perioperative complications were investigated and recorded as well.
Results: Twenty-one patients (M:F = 10:11) were operated in our hospital: 15 cases of LSG, 6 of
LSG/DJB, respectively. Average BMI is 48.5 at first visit and reduced to 44.2 at the time of before
surgery. The body weight was reduced 11.6 kg until surgery: fat tissue reduction is 3.2 kg, and
skeletal muscle reduction is 0.8 kg. There was no over grade-III morbidity and mortality. The body
weight loss at 12 months after surgery is 28.7 kg in average. The fat tissue reduction was 23.3 kg,
and the skeletal muscle reduction was 3.4 kg. Thus, the skeletal muscle reduction was minimum.
Besides, the body fat percentage of LSG/DJB at 12 months after surgery is significantly less than
the LSG group.
Conclusion: Since preoperative VLCD diet reduces mostly fat volume, but not the skeletal muscle
volume, the VLCD diet therapy is safe and acceptable as a preoperative management. The body
weight loss after surgery is also due to the fat tissue reduction, and it was enhanced in LSG/DJB
patients.

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P453
Stand The Stomach Technique Using Auto Irrigation Device
and Endoquick Suture for Sleeve Gastrectomy
Tetsuo Ikeda, MD, PhD, Department of Advanced Medical Initiatives
Graduate School of Medical Sciences
Conclusion: Using the devised techniques, a Japanese gastroenterological surgical department was
able to safely perform bariatric surgery on patients with BMIs of 3575.8 (kg/m2).
Background: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide as a
definitive bariatric procedure. However, there are still some controversial issues associated with the
technique, such as methods of the reliably dissection of gastric fundus, the prevention of the gastric
tube strictures and the reinforcement method of staple line. The aim of this study to evaluate our
stand the stomach technique on the preoperative course of LSG.
Methods: Between November 2013 and March 2015, 43 morbidly obese patients submitted for
LSG were performed. Sixteen case were performed LSG using this technique.
Surgical Technique: All of the procedures were performed under general anesthesia. Patients were
placed in the supine position with opening legs. Initial trocar placement was accomplished through
the umbilicus, under direct vision, using a 12-mm optical trocar with an attached balloon. Pneumoperitoneum was achieved with carbon dioxide to a pressure of 12 mmHg. Four additional ports
were then placed under direct vision.
The dissection was begun by dividing the gastrocolic ligament along the greater curvature of the
stomach approximately 1 cm proximal to the pylorus using a 5-mm EnSeal? (Ethicon EndoSurgery, Blue Ash, Ohio) attached to a SILIGATOR? (auto irrigation silicon tube, Fujisistem
Kanagawa Japan). This dissection was continued towards the gastroesophageal junction. The left
crus was completely freed of any attachments in order to avoid leaving a posterior pouch when
constructing the sleeve in this region. With the stomach held in the cephalad direction, the gastric
transection was started approximately 1 cm proximal to the pylorus using a 60-mm green endostapler (Echelon Flex 60 Endopath), making a circle with the gastric angle as the major axis, and
the greater curvature was resected approximately 1 cm from the gastroesophageal junction. Following the transection of the stomach, the staple line was oversewn using 2/0 and 3/0 Endo Quick
Suture? (Akiyama, Japan) interrupted or continuous intracorporeal suture. At this time, similar to
when the gastrosplenic ligament was detached, the assistant lightly pulled sutures. Finally, for the
resection of the remaining pylorus-proximal region of the stomach towards the caudal side, the
staple line was grasped with the left hand and was simultaneously held upright along with the
lateral segment of the liver and this segment was sutured.

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P454

P456

Operative Time in Sleeve Gastrectomy: Influence of Preoperative

Factors in Relation to Perioperative Complications

The Effects of Bariatric Surgery on Inflammatory Markers

for Cardiovascular Diseases

Luciano J Deluca, MD, Patricio J Cal, MD, Tomas C Jakob, MD,

Ezequiel O Fernandez, MD, Centro de Rehabilitacion Quirurgica de
la Obesidad (CRQO)

Ali Kagan Coskun, MD1, Ali Harlak, MD1, Turgay Celik, MD2,
Taner Yigit, MD1, Cengiz Ozturk, MD2, Tuncer Cayci, MD3, 1GATA
Dept. of Surgery, 2GATA Dept. of Cardiology, 3GATA Dept.
of Biochemistry

Introduction: There is evidence that surgical time is directly related to perioperative morbidity and
mortality. Bariatric surgeries are the most effective treatment for morbid obesity and its co morbidities. Among them, laparoscopic sleeve gastrectomy (LSG) has become a low morbidity
procedure with wide acceptance and excellent results.
Methods and Procedures: Our goal was to evaluate the relation of surgical time in LSG with
preoperative factors such as BMI and preoperative weight loss and its correlation with perioperative morbidity and mortality. Between June 2014 and August 2015, 455 patients undergoing LSG
were included. All surgeries were performed by the same two surgeons. Data was collected
prospectively. Operative time was measured from placement of the first trocar to extraction of the
last one. Anthropometric characteristics, previous abdominal surgery, preoperative weight loss,
perioperative complications, perception of difficulty by the surgeon according to dietary preparation and surgical time were evaluated.
Results: Mean BMI was 46.01 kg/m2 (35.378.4), mean age was 42.9 (1674) and 82.6 % were
women. Preoperative weight loss was 12.2 % of initial body weight (2.1729.6). Average operating
time was 30.9 minutes for Surgeon 1 and 31.4 minutes for Surgeon 2 (P = NS). Dividing patients
into 4 groups by BMI (\45, 45 to \50, 5055, [55) operative time was 30.6; 31.7; 30.2 and 33.4
minutes, being the last one significantly longer than the other groups. Dividing patients into 3
groups according to preoperative weight loss ([13 %, 1013 % and \10 %), surgical time was
30.6; 31 and 32.3 minutes respectively (P = NS). There was no correlation between preoperative
BMI or weight loss and surgical time (r = 0.09 and r = -0.02). Surgery in men lasted 34.3
minutes vs. 30.5 in women (P = 0.001). There was no significant difference between patients with
and without previous surgery (31.1 vs. 31.2). Twelve major complications (2.63 %) were recorded
in the group (2 leaks, 1 intraabdominal abscess and 9 major bleedings). Surgical time for patients
who had complications was 29.6 vs. 31.2 minutes for the uncomplicated (P = NS). When the
surgeons perception of preparation was good, operatory time was 30.5 minutes vs. 32.9 minutes, it
was perceived as poor (P = 0.02).
Conclusion: Surgery was significantly longer on patients with higher BMI, in men, and in those
whose preparation seemed poor. Pre operative weight loss should be emphasized in the super-obese
and in men.

Background: The prevalence of obesity (BMI [ 30 kg/m2) has an increase in the last two
decades. Obesity is defined as a risk factor for cardiovascular diseases by World Hearth
Federation. Inflammation plays an important role in cardiovascular diseases. One of the
common causes of cardiovascular disease is atherosclerosis which is a complex inflammatory process, is seen at obese patients. In recent studies, the neutrophil/leukocyte ratio,
red cell distribution width and mean platelet volume were evaluated for being an inflamatory markers in cardiovascular diseases. We aimed to evaluate the levels of inflammatory
markers for cardiovascular diseases undergoing bariatric surgery in obese patients at
Gulhane Military Medical Academy.
Methods: The study consisted of 75 obese patients undergone bariatric surgery. Age, sex,
body mass index, operation type, cardiovascular risk factors, white blood cell count neutrophil-to-lymphocyte ratio, platelet count, mean corpuscular volume, mean corpuscular
hemoglobin, mean corpuscular hemoglobin concentration, platelet distribution width and
red cell distribution width were taken from hospital records and surgeons notes (including
post-operative patients control). The data before the operation and aproximately 1 year after
the operation were compared and evaluated.
Results: Of the 75 patients, 56 of them undergone laparoscopic gastric by-pass and the
other 19 of them were operated with sleeve gastrectomy technic. The average decrease at
BMI levels was 34 %. The cardiovascular disease risk was detected at 44 patients. The
comparision between pre-operative and post-operative first year results of the markers of
the patients who had cardiovascular risk factors resulted with significant difference
(p \ 0.05) for white blood cell count, neutrophil-to-lymphocyte ratio, platelet count, mean
corpuscular volume, mean corpuscular hemoglobin and platelet distribution width.
Conclusion: Our study results showed that in the light of inflammation, the cardiovascular
risk may be reduced with BMI decrease following bariatric surgery. However these significant changes in inflammation should be evaluated in terms of clinical implications with
in large groups of patients.

P455
P457
Indications for Conversion from Sleeve Gastretomy to Roux-en-Y
Gastric Bypass
Thomas J Buddensick, MD, Michael Kammerer, MD, Alec Beekley,
MD, David Tichansky, MD, Thomas Jefferson University
Introduction: As sleeve gastrectomy (LSG) continues to grow in popularity, a noticeable
subset of patients has evolved that undergo revisional surgery after LSG; specifically
conversion to roux-en-Y gastric bypass (RYGB). Knowledge of the indications for conversion may allow for earlier identification of patients in need of revision. We present our
subset of patients who underwent this procedure over a 30-month time period.
Methods: A retrospective review of a prospectively maintained bariatric surgery database
was performed on a single institutions data from patients undergoing surgery between 2013
and 2015. Medical history, weight loss and surgical indications were reviewed in all
patients undergoing conversion from LSG to RYGB.
Results: Four patients underwent conversion from LSG to RYGB during the reviewed time
period. Indications were severe gastroesophageal reflux (n = 3) and weight regain (n = 1).
All patients with gastroesophageal reflux were found to have a hiatal hernia at re-exploration. One of these had undergone a hiatal hernia repair at initial operation. All hernias
were repaired at subsequent operation. One of these patients was found to have severe
angulation in the sleeve with proximal gastritis that likely contributed to reflux symptoms.
Two of the three patients who underwent conversion for gastroephageal reflux underwent
post conversion upper endoscopy. These evaluations were performed at four and seven
months respectively and showed no evidence of esophagitis or recurrent hiatal hernia. The
patient requiring conversion due to weight regain had a BMI of 52 prior to LSG. Maximal
weight loss was reached at 15 months with a BMI nadir of 37. At the time of conversion,
26 months postoperatively, BMI was 42. In this patient, upper gastrointestinal series and
endoscopy revealed a dilated sleeve more than twice its original diameter which was
confirmed intraoperatively. At 12 months post conversion, BMI was 38.
Conclusions: In our series, severe gastroesophageal reflux and weight regain were the
indications for conversion from LSG to RYGB. Of the two, severe reflux seems to be more
common and was associated with recurrent or previously unrecognized hiatal hernia.

Outcomes of Bariatric Surgery in Patients of Lower

Socioeconomic Status Versus Patients of Higher Socioeconomic
Status
Aaron Purser1, Angel Farinas, MD2, Christian Cruz, MD2, Angelina
Postoev2, Christopher Ibikunle, MD2, Aliu Sanni, MD2, 1GRU/UGA
Medical Partnership, 2Georgia Surgicare
Introduction: Patients who undergo bariatric surgery are disproportionately middle aged
white women with private insurance. Previous data has shown that those who have publicly
funded insurance (Medicare/ Medicaid) or are described in a low socioeconomic class have
decreased access for surgery. While this disparity has been established, there has been a
lack of research analyzing the outcomes of bariatric surgery in patients who have publicly
funded insurance/low socioeconomic class compared to those using commercial/private
insurance/high socioeconomic class. This study was designed to address this concern.
Methods: A systematic review was conducted through PubMed to identify relevant studies
with comparative data on bariatric patients who represent lower socioeconomic classes
compared to those in higher socioeconomic classes. Selection criteria was based on
socioeconomic status, median household annual income, and primary insurance carrier. The
primary outcome was mortality. Secondary outcomes addressed weight loss (or decrease in
BMI), mean length of stay in the hospital, postoperative comorbidities, and availability to
follow-up. Results are expressed as standard difference in means with standard error.
Statistical analysis was done using fixed-effects meta-analysis to compare the mean value
of the separate groups (Comprehensive Meta Analysis Version 3.3.070 software; Biostat
Inc., Englewood, NJ).
Results: Four out of 64 studies identified were quantitatively assessed and included for
meta-analysis. This data included three retrospective studies and 1 prospective study.
Among the four studies, 295 patients were specifically identified as socioeconomically
deprived or dependent on Medicaid/Medicare, 47 patients were listed as self-financed, and
905 were privately/commercially insured. The postoperative mortality rate was found to be
higher in the publicly funded group (4.8 % vs. 0.8 %, p \ 0.007) when compared to the
private/commercial insurance group. Patients in the private medical insurance group lost
more excess weight (0.280 0.132, p \ 0.034) compared to those with publicly funded
insurance. Additionally, individual studies suggest that socioeconomically deprived patients
and those on Medicaid have a greater chance of readmission (18 % vs. 10 %) and residual
sleep apnea (17.9 % v 7.1 %, p \ 0.0003).
Conclusions: Patients in the low socioeconomic class have worse post operative bariatric
surgery outcomes when compared to those in the high socioeconomic class.

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P458

P459

Sleeve Gastrectomy Can Be Safely Performed Without Staple

Line Reinforcement

Approach to the Care of the Pregnant Patient After Bariatric

Surgery: A Bariatric Surgeons Perspective

Cullen O Carter, MD1, Matthew Tufts2, Myron S Powell2, Stephen S

McNatt2, Adolfo Z Fernandez2, 1Boston Medical Center, 2Wake
Forest Baptist Medical Center

Daniel Skubleny1, Noah J Switzer2, Richdeep Gill3, Daniel Birch2,

Shahzeer Karmali2, Chirstopher de Gara2, 1Faculty of Medicine
and Dentistry, University of Alberta, 2University of Alberta,
3
University of Calgary

Introduction: Since 2012, sleeve gastrectomy has been the most common bariatric surgical
procedure performed in the United States. According to recent surveys, 79 % of bariatric
surgeons perform some form of staple-line reinforcement, with 57 % using staple-line
buttressing with a biologic material and 43 % oversewing the staple line. Buttressing with
biologic material and oversewing can add significant cost and time, respectively, to the
surgical procedure. The purpose of this study was to review the experience of sleeve
gastrectomy at a single institution performed without any form of staple-line reinforcement.
Methods and Procedures: A retrospective chart review of all patients who underwent
sleeve gastrectomy performed by two surgeons at a single institution was undertaken.
Operative note, laboratory values, vital signs, progress notes, and discharge summaries
were reviewed, looking specifically for evidence of bleeding or staple-line leak.
Results: A total of 345 patients underwent sleeve gastrectomy over a period of three years.
The perioperative 30-day mortality rate was 0 %. Leak rate was 0 %. Eight patients (2.3 %)
showed clinical signs of bleeding. The most commmon signs were tachycardia, hypotension, orthostasis, syncope, and oliguria. The average decrease in hemoglobin in this group
was 4.9 g/dl. Three patients required intervention for bleeding (0.9 %). The first required
reoperation with control of a pulsatile stable line bleed and transfusion of 1 unit RBC. The
second required transfusion of 1 unit RBC but did not require reoperation. The third patient
had a subcutaneous bleed into a single incision port site which required reoperation for
hematoma evacuation, but did not require peritoneal entry or transfusion.
Conclusion: Sleeve gastrectomy can be safely performed without staple line reinforcement
or buttressing, with a very low rate of clinically signficant bleeding.

123

Introduction: We present a review of the literature on the pregnant patient with a prior history of bariatric
surgery, highlighting 4 common presentations: internal hernia, gallstone disease, nutrient deficiency and
management of the laparoscopic adjustable gastric band (LAGB). Bariatric surgery is now a common
procedure among reproductive age women. Although bariatric surgery improves pregnancy outcomes for
both mother and fetus when compared to non-bariatric obese controls, it has been shown to be associated
with unique physiologic and surgical complications during pregnancy.
Methods and Procedures: A literature search of electronic databases PUBMED, MEDLINE, EMBASE,
SCOPUS and Web of Science using keywords and phrases relating to bariatric surgery and pregnancy and
internal hernia or nutrition or gallstone disease or vomiting was conducted. English articles of all publication
types published from 19952015 were considered for review.
Results: Failure to identify complications associated with internal hernia, gallstone disease, nutritional
deficiency and the laparoscopic adjustable gastric band can have detrimental consequences to both mother
and fetus. The possibility of internal hernia must be considered in the pregnant woman with abdominal pain
and obstructive symptoms. Radiologic imaging is often low yield and early surgical intervention is associated with improved outcome. Clinical observation and diagnosis with subsequent laparoscopy/laparotomy
is an effective and safe treatment. If possible, early surgical intervention for gallstone disease during
pregnancy is optimal due to procedural safety and higher risk of adverse events and miscarriage with
delayed treatment. Bariatric surgery is associated with numerous nutrient deficiencies including folic acid,
Vitamins A, D, K and B12 and iron and can cause adverse fetal events. Physicians must engage in close but
logical monitoring of nutrient deficiency and provide supplementation if necessary. The LAGB should
remain inflated except in the event of symptomatic nausea and vomiting or if the patient is not gaining
appropriate weight.
Conclusion: Special considerations must be made in the approach to the pregnant patient after bariatric
surgery. Our recommendation for these patients is to ensure close multidisciplinary follow up during
pregnancy to assess maternal nutritional status and weight gain. In the event of suspected internal hernia or
gallstone disease consultation of a general or bariatric surgeon should be sought and if indicated, surgical
intervention should not be delayed.

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Upper GI Studies Following Laparoscopic Sleeve Gastrectomy:

A Study that Prolongs Length of Stay

Revisional Laparoscopic Sleeve Gastrectomy: A Viable Option

After Gastric Band Failure

Renee M Tholey, MD1, Jonathan Abelson, MD1, Sara Hassen1,

Daniel Benhuri2, Gregory Dakin, MD1, Alfons Pomp, MD1,
Cheguevara Afaneh, MD1, 1New York Presbyterian Hospital- Weill
Cornell Medical College, 2University of Toledo

Talar Tatarian, MD, Michael Kammerer, MD, Danica Giugliano, MD,

Alec Beekley, MD, David Tichansky, MD, Thomas Jefferson
University Hospital, Philadelphia, PA

Introduction: Bariatric surgery, comprised mostly of laparoscopic sleeve gastrectomy (LSG) and roux-en-y
gastric bypass, is rapidly on its way to becoming the most common major general surgery procedure
performed in the United States. The purpose of our study was to determine factors affecting length of stay
(LOS) following LSG.
Methods and Procedures: One hundred eighty-seven patients underwent LSG in an academic teaching
hospital over two six month periods in 2013 and 2014. Patients were selected by their surgeon to undergo a
routine Upper GI (UGI) study on postoperative day one (UGI group) or to proceed directly to a liquid diet
without the radiographic study (No-UGI group). Primary endpoint was LOS. Secondary endpoint was
surgical morbidity.
One hundred thirty-four patients were in the UGI group and fifty-three patients were in the No-UGI group.
The two groups were matched for gender, age, body mass index (BMI), American Society of Anesthesiology
(ASA) score, and the following preoperative co-morbidities: hypertension, diabetes mellitus, and
hyperlipidemia.
Results: Perioperative parameters are listed in Table 1. Postoperative complications were 8 % in the UGI
group and 4 % in the No-UGI group (p = 0.28). There were no leaks and no significant difference in 90 day
readmission rates (p = 0.44).
Length of stay was 58.9 hours in the UGI group and 51.4 hours in the No-UGI group (p = 0.009) (Fig. 1).
Multivariate logistic regression analysis was used to identify independent predictors of a LOS [ 48 hours.
Both forward and backward stepwise regression analyses were utilized removing parameters with a
P [ 0.15. Variables with a P \ 0.15 were included as well as ASA, BMI, and occurrence of a postoperative
complication.
Performing a postoperative UGI study was the strongest predictor of a LOS [ 48 hours with an odds ratio
(OR) of 1.524 (p = 0.01) followed by increasing ASA score (OR = 2.18, p = 0.03) (Table 2).
Conclusions: We conclude that patients undergoing a postoperative UGI study are more likely to have an
increased LOS as compared to those patients in the No-UGI group with no difference in surgical morbidity,
leak rate, or readmission rate. Eliminating routine UGI studies following LSG is an effective strategy to
decrease LOS.

Introduction: Laparoscopic adjustable gastric banding (LAGB) for weight loss has decreased in popularity
in recent years, secondary to published high failure, complication and explantation rates in the long-term.
Band removal with concurrent sleeve gastrectomy (LSG) seems to help these patients and allow for more
durable weight loss. Herein, we investigate revisional LSG after LAGB to determine the weight loss and
comorbidity outcomes of patients undergoing this conversion.
Methods: A prospectively maintained bariatric surgery database was retrospectively queried to identify all
patients who underwent simultaneous LAGB removal and LSG from August 2012 to December 2014.
Patient demographics, medical history, operative details and percentage of excess weight loss (%EWL) were
examined.
Results: Thirteen patients underwent simultaneous LAGB removal and LSG during the study period.
Twelve patients were female. Median age was 46 years old. Indications for surgery included: failure to lose
weight (n = 10), dysphagia (n = 3), gastroesophageal reflux (n = 2), and persistent hypertension (n = 2).
Preoperative co-morbidities included: hypertension (46.2 %), back pain (46.2 %), gastroesophageal reflux
(46.2 %), obstructive sleep apnea (38.5 %), hyperlipidemia (15.4 %), and diabetes mellitus (7.7 %). All
procedures were completed laparoscopically with no complications or mortalities. Average follow-up was
15 months. Average pre- and post-operative BMI (kg/m2) was 44.3 and 37.3 respectively with average %EWL = 33.8 %. Three patients with back pain (50 %) and three patients with reflux symptoms
(50 %) had complete resolution of these symptoms. Four patients hypertension improved (66 %), no longer
requiring at least one of their anti-hypertensive medications.
Conclusions: Revisional LSG after failed LAGB is a safe and feasible option yielding additional weight loss
with complications outcomes similar to de novo sleeve gastrectomy.

Table 1 .

Fig. 1 .
Table 2 .

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A Multidisciplinary Approach to Reduce Postoperative

Readmission After Bariatric Surgery in a Single Institution

Gastroesophageal Reflux Following Sleeve Gastrectomy: A MetaAnalysis

Joon K Shim, MD, MPH, FACS1, G D Roye, MD, FACS1, Beth

Ryder, MD, FACS1, Todd Stafford, MD1, Kellie C Armstrong, RN,
BSN, MS, CBN2, Debi A Diana, MA2, Sivamainthan Vithiananthan,
MD, FACS1, 1Brown University, 2Miriam Hospital

Christopher Crawford, MD, Daniel Lomelin, MPH, Kyle Gibbens,

BS, Crystal Krause, PhD, Dmitry Oleynikov, MD, University
of Nebraska Medical Center

Introduction: Bariatric surgery patients are at a risk of requiring readmission after their index
operation. In this study, we report a 14 month experience identifying and reducing postoperative
readmissions within 30 days after bariatric surgery performed at a single teaching institution.
Methods: 272 morbidly obese patients underwent laparoscopic and open roux-en-y gastric bypass
(LGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable LAP-BAND (LAGB)
placement or revisional surgery from June 2012August 2013 at our bariatric center. Pre-intervention date was June 1, 2012 to Dec 31, 2012. Post-intervention date was Feb 1, 2013 to August
31, 2013. We established a multidisciplinary committee to review the readmission rate. All
readmissions were reviewed. The majority of potentially avoidable readmissions were related to
nausea and vomiting. Our readmission reduction process focused on the following key areas:
additional teaching in our preoperative classes, outreach education to local visiting nurses, the
addition of metoclopramide to our routine discharge medications, providing visiting nurses to all
bariatric patients, increasing availability of dieticians, 24/7 availability of our bariatric nurse
coordinator to all patients, having access to outpatient intravenous hydration, and making follow-up
Friday phone calls to all bariatric patients.
Results: A total of 134 patients underwent bariatric surgery from June 1, 2012 to Dec 31, 2012.
There were 12 readmissions during this period, 6 of which were related to nausea and vomiting.
The multidisciplinary committee met and planned interventions in January 2013. From February
2013 to August 2013, a total of 138 patients underwent bariatric surgery, 7 of whom were readmitted. Only 1 patient was readmitted for nausea and vomiting. The overall post intervention
readmission rate was 5.1 %, down from 8.9 % prior to our intervention. The post intervention
readmission rate related to nausea and vomiting was 0.7 %, down from 4.5 % prior to our
intervention.
Conclusion: A multidisciplinary committee can design and effectively implement a strategy to
improve readmissions rates for bariatric surgery patients. As the majority of our readmissions were
related to postoperative nausea, we saw a clear opportunity to target improvement. Engaging
patients and improving the entire process of postoperative care to ensure compliance with these key
measures are critical to a programs success.

Introduction: Symptomatic gastroesophageal reflux remains a persistent problem following sleeve

gastrectomy (SG). SG decreases the volume and compliance of the stomach. Dissection performed
at the angle of His can decrease the acute angle, allowing fluid to reflux into the esophagus. The
altered anatomy of the GE junction and conversion to a high-pressure system makes SG patients
more likely to develop gastroesophageal reflux disease (GERD) than those with native anatomy or
those undergoing gastric bypass.
Methods: A meta-analysis of the literature was performed to identify studies of bariatric patients
undergoing SG that evaluated the pre-operative and post-operative incidence of GERD. If hiatal
hernia repair (HHR) in addition to SG was described, that was analyzed as a separate characteristic.
This was reported in 3 studies with 210 total patients. Descriptive statistics were calculated for
change in GERD prevalence, pre and post-operatively, using SPSS v20.0.0.0 and with each study
weighed by sample size.
Results: A total of 29 studies were identified with at least 6 months of follow up, with a pooled
sample size of 8,723 patients. In patients who underwent SG alone, 78.4 % of 2,474 patients with
pre-operative GERD still had GERD post-operatively. In patients who underwent SG and concurrent HHR, only 15.1 % of 116 patients who had pre-operative GERD still had GERD postoperatively (p \ 0.001, odds ratio 20.4).
In studies that reported overall pre- and post-operative GERD (n = 7,729), the pre-operative
prevalence of GERD was 39.5 %, and the post-operative prevalence was 30.1 %, (p \ 0.001). One
large study did not include pre-operative incidence of GERD, only de novo onset, and was
excluded from that portion of our analysis.
Patients who did not have GERD pre-operatively did not typically develop GERD, regardless of the
addition of a HHR. The onset of GERD occurred in 9.5 % of patients following SG and 10.6 % of
patients following SG + HHR, with no significant difference (p = 0.708).
Conclusions: Despite awareness of GERD being a potential complication following SG, 78 % of
patients with GERD do not have symptom improvement or resolution with SG, with 30.5 % of all
patients experiencing GERD symptoms following SG. Patients with GERD and a hiatal hernia
show improvement in GERD following SG by including a HHR. Proper patient selection as well as
operative technique focused on limiting the prevalence of GERD should remain a paramount
concern.

P463

P465

Subsequent Cholecystectomy Rate After Bariatric Surgery

in Morbid Obesity Patients: A Systematic Review and MetaAnalysis

Effect of Sleeve Gastrectomy on Control of Type 2 Diabetes

Mellitus in our Series

Ajaree Sattaratnamai, MD1, Noppawat Samankatiwat, MD1, Suthep

Udomsawaengsup, MD2, 1Ratchaburi Hospital, 2King Chulalongkorn
Memorial Hospital

Nandakishore Dukkipati, MD, Deepti Thakkar, LivlifeHospitals

Introduction: Recently, the rate of bariatric surgery in morbid obesity patients is continuously
increasing. After bariatric surgery, rapid weight loss increases the risk to develop gallbladder
disease. Gallbladder management in bariatric surgery is still controversial whether to perform
cholecystectomy only in symptomatic patients or prophylactically. The purpose of this study is to
review the studies about the rate of gallstone and the need of subsequent cholecystectomy after
bariatric surgery.
Method: We conducted a MEDLINE, PubMed, EMBASE, SCOPUS, and Google Scholar search
up to August, 2015. Two investigators independently searched all the studies about incidences of
symptomatic gallstone and cholecystitis that warranted cholecystectomy after bariatric surgery
were included in this meta-analysis. Comprehensive Meta-Analysis (Ver.3) was used to analyze the
data.
Results: 21 studies met the inclusion criteria. 18 studies investigated in patients who underwent
Roux-en-Y gastric bypass (RYGB), 2 studies of sleeve gastrectomy (SG) and 6 studies of
adjustable gastric banding (AGB). Total number of patients is 13,627. The number of patients
without previous or concomitant cholecystectomy is 7,505 in Roux-en-Y gastric bypass group, 285
in sleeve gastrectomy group and 1,677 in adjustable gastric banding group were studied. The
indications for subsequent cholecystectomy are mostly symptomatic gallstone and acute cholecystitis. In Roux-en-Y gastric bypass group, the rate of subsequent cholecystectomy is
8.6 %(95 %CI, 6.211.7 %), in sleeve gastrectomy group is 4.7 %(95 %CI,1.612.8 %), in
adjustable gastric banding is 6.6 %(95 %CI,3.612.0 %). The rate of subsequent cholecystectomy
has no significant difference when compared between AGB and RYGB, AGB and SG, SG and
RYGB (p-value 0.29, 0.28 and 0.12 respectively). Overall, the rate of patients who need subsequent
cholecystectomy is 7.8 % (95 %CI, 6.010.1 %). The reasons for subsequent cholecystectomy are
symptomatic gallstone 79.84 %, acute cholecystitis 15.50 %, common bile duct stone with
obstructive jaundice 2.32 %, biliary pancreatitis 2.32 %.
Conclusion: From the meta-analysis, the rate of patients that required subsequent cholecystectomy
after each group of bariatric surgery (RYGB, SG or AGB) has no significant difference and the rate
of subsequent cholecystectomy in is low. Therefore, prophylactic cholecystectomy may be
unnecessary for every patient at the time of bariatric surgery.

123

Introduction: An estimated 80 % of Type 2 Diabetes is related to Obesity. Weight loss induced by

bariatric surgery is a major factor of diabetes improvement. Our aim in this study was to see the
effect of Laparoscopic Sleeve Gastrectomy on control and remission of Diabetes and also to see the
difference in improvement of Diabetes based on distance of resection from the pylorus.
Materials and Methods: All LSG patients between Jan 2012 to Dec 2014, who were diagnosed
cases of type 2 Diabetes preoperatively, were followed up and their current BMI, diabetic medication usage, fasting blood glucose and HbA1c levels were documented. Remission of diabetes was
defined as discontinuation of diabetic medications, concurrent with normalization of fasting glucose (\110 mg/dl) and HbA1c (B6). Improvement was defined as either a decrease in HbA1C level
or a reduction in the antidiabetic treatment. We measured and recorded the Distance of resection
from Pylorus during surgery for all patients.
Results:35 Diabetic obese patients underwent Laparoscopic gastric sleeve between Jan 2012 and
Dec 2014. 12 were females and 23 were males. Their average age was 45 years and average BMI
was 42.23 kg/m2. 8 patients were on Insulin and remaining 27 were on Oral Hypoglycemic agents
(OHA) before surgery. Post operatively, 27 out of 35 i.e. 78 % patients were off all medications for
Diabetes. 6 patients were still on OHAs and only 2 patients still need Insulin for control of blood
sugars. However all patients witnessed improvement in sugar levels with a reduction in dosage of
medications. 20 out of 35 patients i.e. 57.14 % patients had complete remission of Diabetes.
Resection distance from pylorus less than 2 cm was found to significantly affect remission rate
(p = 0.034). Also patients with less than 2 yrs diabetes were significantly more likely to have
remission than those with more than 2 yrs Diabetes history (p = 0.001). However, percentage
excess weight loss did not affect remission rates.
Conclusions: Laparoscopic Gastric Sleeve surgery can induce a significant and sustainable
remission and improvement of T2DM in severely obese patients. This study is one of the few
studies where antral resection distance was co-related to improvement of Diabetes. However this
study is retrospective with a small sample size and a short follow up period. More prospective
studies with larger sample size and longer follow up period are required to confirm these results.

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Resolution of Diabetic Nephropathy Following Laparoscopic Ileal

Interposition with BMI-Adjusted Sleeve Gastrectomy in Patients
with Type-2 Diabetes: Multi-Center Study

Long-Term Analysis of Risk For Anemia in Laparoscopic Rouxen-Y Gastric Bypass Patients with At Least 5-Year Follow Up

Surendra Ugale, MD, Kirloskar Hospital & Asian Bariatrics

Introduction: Diabetic nephropathy is the leading cause of chronic kidney disease, and associated
with increased cardiovascular mortality. 3040 % of diabetics develop nephropathy. The aim of
this study was to evaluate the regression of nephropathy in poorly controlled type-2 diabetics
(T2DM), by laparoscopic ileal interposition with BMI-adjusted sleeve gastrectomy (IISG), through
better glycemic control, even in non-obese patients.
Methods: This was a retrospective, 2-center study in 60 patients. 51 were men and 21 women.
Mean age was 50.7 years (2270). Mean BMI was 33.8 kg/m2 (23.551). Insulin therapy was been
used by 41 % of the patients. Mean duration of T2DM was 11.5 years (332). Mean HbA1c was
9.2 % (6.115.8). Microalbuminuria (30299 lg/min) was diagnosed in 47 % of the patients and
macroalbuminuria ([300 lg/min) in 53 %. The mean clearance of creatinine was 62.2 mL/min
(33128). 48 % of the patients had creatinine clearance B 60 mL/min. Arterial hypertension
present in 66 %.
Results: Mean post-operative follow-up was 14 months (860). Mean postoperative BMI was
25.2 kg/m2 (19.834.5). Mean HbA1c was 6.9 % (5.29.6). Overall, 52.4 % of the patients
achieved remission of T2DM. Microalbuminuria was normalized in 89 %. Macro-albuminuria
persisted in 8.6 %. The mean clearance of creatinine was 98 mL/min (48 - 120). Arterial hypertension was controlled in 90 % of the patients
Conclusion: Laparoscopic IISG seems to be a promising procedure to control diabetic
nephropathy, possibly through remission of micro-albuminuria and T2DM.

P467
Endoscopic Management of Leak Following Sleeve Gastrectomy:
Case Series and Literature Review
Jonah Klein, MD1, Rohit Soans, MD2, Jennifer Maranki, MD2,
Michael Edwards, MD, FACS2, 1Lankenau Medical Center, 2Temple
University Hospital
Background: There has been an increase in the use of sleeve gastrectomy for operative weight
management, and a parallel increase in the incidence of post-operative leak. There is no accepted
classification system or treatment algorithm for these leaks, and the management is often multistep
and multidisciplinary. We aim to assess the endoscopic strategies for leak management and review
the literature on attempts to classify staple line leaks
Methods: Two representative complex cases of leaks following sleeve gastrectomy managed
endoscopically are reviewed. Additionally, a systematic electronic review of the literature using the
MEDLINE database and individual reference checks yielded 5 studies between 2012 and 2015
discussing institutional experiences with endoscopic management of sleeve gastrectomy leaks.
Keywords included sleeve gastrectomy, leak, and endoscopic. An additional 4 studies
proposing classification and management schemes for leaks were reviewed.
Results: Our endoscopically managed cases presented with leaks at post-operative days 67 and 12.
One patient underwent initial surgical repair and drain placement without resolution. All other
interventions were endoscopic and both patients achieved leak resolution on post-operative days
137 and 98 respectively. Of the 5 articles reviewed, the total number of patients with leaks treated
endoscopically were 47. The percentage of sleeve gastrectomy patients with leaks ranged from
1.52.8 %. The average time to leak ranged from 727.2 days. The initial endoscopic intervention
for all but one patient was stenting. Of the patients treated endoscopically, 34 (72 %) achieved leak
resolution with only endoscopic intervention. Classification methods have been proposed using
post-operative day, CT findings of collection size, number of collections, CT evidence of leak, and
leak size, but no method has been consistently validated.
Conclusion: Endoscopic treatments for staple line leak in sleeve gastrectomy are less invasive
approaches to achieve leak resolution. Continuing to treat patients endoscopically will provide
more information on outcomes to better guide decision making and to propose an accepted classification system and algorithm for management.

Piotr J Gorecki, MD2, Christine M Najjar, MS1, Krystyna Kabata,

PA2, Anthony Tortolani, MD2, 2New York Methodist Hospital, 1St.
Georges University School of Medicine
BACKGROUND: Short-term benefits of laparoscopic Roux-en-Y gastric bypass (LRYGB) are
well known and it remains the treatment of choice for morbid obesity. Prevalence of anemia in
bariatric surgery candidates has been reported in 10 % to 40 % of patients. Few long-term studies
evaluate the prevalence of anemia after LRYGB. Our study analyzes the incidence of anemia in
LRYGB patients with at least 5-year follow up.
Methods: Fifty-five patients operated on between August 2001 and August 2004 in a single
institution by a single surgeon utilizing the same technique were analysed. All data was collected
prospectively. Patients with at least one charted hemoglobin (Hb) level 5 or more years after
surgery were included. Females and males were considered anemic with Hb levels of\12 g/dL and
\13.5 g/dL, respectively. Incidence of anemia and follow-up Hb levels were compared to preoperative Hb levels using a paired two-sample t-test.
Results: There were no conversions to open surgery and no perioperative mortalities. Average
preoperative patient age and BMI were 35.6 years and 48.2 kg/m2, respectively. Females represented 89 % of patients. See tables.
Follow-up
Period

n = Patients
(M)

Mean
(M)

Hb SD

Pvalue
(M)

n = Patients
(F)

Mean Hb SD
(F)

Pvalue
(F)

Pre-op

14.98 1.24

46

12.85 1.15

3m

14.54 1.75

0.6482

38

12.76 1.06

0.7201

12 m

14.57 1.71

0.6974

33

12.68 1.23

0.5335

24 m

14.9 2.38

0.9517

21

11.55 1.52

0.0015

35 y

14.9 2.07

0.7347

30

11.51 1.32

0.0001

69 y

14.9 2.54

0.4271

39

11.41 1.52

0.0001

[10 y

14.9 1.21

0.0994

36

10.95 1.78

0.0001

A worsening anemia becomes statistically significant at the 24-month period (p = 0.0038). Mean
decrease in Hb for females becomes significant at 24-months and continues to decrease in all
follow-up periods. 21.7 % of females are anemic in the pre-operative period and 69.4 %
(p = 0.001) are anemic 10 years after LRYGB.
Conculsion: Patients undergoing LRYGB are at risk of developing anemia at long-term follow.
This risk is greater for females and increases each year after LRYGB.

P469
Algorithm for Ordering Abdominal CT Scans in Patients After
Gastric Bypass: Is it Possible?
Luise I Pernar, MD1, Ryan Lockridge, BS, BSN, RN1, Colleen
MccCormack1, Minghua Chen, MD, PhD1, Judy Chen, MD2, Scott
A Shikora1, David Spector3, Ali Tavakkoli3, Malcom K Robinson,
MD1, Ashley H Vernon3, 1Brigham and Womens Hospital, 2Swedish
Medical Center, 3Brigham and Womens Faulkner Hospital
Introduction: Gastric bypass patients frequently present to the emergency department (ED) with
complaints for which abdominal CT (abdCT) scans are ordered. This is done to rule out potentially
catastrophic complications such as an internal hernia or anastomotic leak. However, anecdotally,
the majority of such scans do not reveal intra-abdominal pathology. Given the health care costs of
potentially unnecessary CT scans and risks of radiation exposure, this study was undertaken to
determine if clinical and laboratory parameters could be used to develop an algorithm for more
rational ordering of abdCTs.
Methods: The study is a retrospective review of patients who underwent primary open or
laparoscopic Roux-en-Y gastric bypass (RYGBP) who presented to the ED with complaints
potentially related to their RYGBPs regardless of whether an abdCT was ordered. Data were
collected on a variety of symptoms, signs, and laboratory data. All abdCT scan results were
reviewed and classified as normal or abnormal. We searched for parameters that could reliably
predict a normal or abnormal CT scan.
Results: 1643 primary RYGBs were performed at our institution between 2005 and 2015. 355
patients (22 %) had a total of 675 ED visits; during 390 visits (58 %) abdCT scans were performed.
Of the total number of abdCT scans performed 244 (63 %) were normal and 46 (12 %) demonstrated intra-abdominal pathology that required surgical intervention, related to prior bariatric
surgery in 39 (10 %). The remaining 25 % required either endoscopy, IR intervention, or other
therapy. A history of abdominal pain was sensitive (0.98) but had poor specificity (0.03) for
predicting whether an abdCT scan would be normal or abnormal. Abdominal tenderness had poor
sensitivity (0.71) and specificity (0.24) for predicting the results of an abdCT scan. Other factors
including any level of temperature, heart rate, blood pressure, WBC, lactic acid level, and lipase
were highly insensitive and non-specific and could not be used to reliably predict abdCT scan
results.
Conclusions: RYGB patients frequently have abdCT scans when they present to the ED but are
infrequently found to have intra-abdominal pathology upon scanning. Despite examining a wide
variety of sign, symptoms and lab data we could not identify a parameter which could reliably
delineate those for whom it is safe to forgo an abdCT. ED evaluation and imaging decisions must
be based on astute clinical judgment and do not appear to be amenable to a simple algorithm.

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What Influences Bariatric Surgery Outcomes?: A Multiple

Regression Analysis of the Ontario Bariatric Registry

*Abstract Title: Endoscopic Intragastric Ballon: 2 Years

Experience in an Outpatient Facility

Uri Kaplan, MD, Wael Zohdy, MD, MSc, Scott Gmora, MD, Dennis
Hong, MD, MSc, Mehran Anvari, MD, PhD, McMaster University

Daniel Gomez, MD, Jesus Rodriguez, MD, Gastromedica

Background: A number of factors have been proposed to impact the outcome of bariatric
surgery. The aim of this study was to evaluate the relative influence of various factors
which may impact patient selection and preparation.
Methods: The Ontario Bariatric registry is a prospective data base of all patient undergoing
bariatric surgery in 9 centers of excellence in Ontario. We analyzed the data on all patients
who underwent Laparoscopic Gastric Bypass (LRYGB) or Laparoscopic Sleeve Gastrectomy (LSG) between January 2010 and May 2013. Two early outcomes (90 days) were
analyzed: 1. Composite adverse events (Any of the following: Death, DVT, Stroke, Failure
to discharge, reintervention, anastomotic leak and Cardiopulmonary complication), 2.
Readmission. In addition, three late outcomes at one year were analyzed: 1. Percentage of
excess body weight loss (%EBWL), 2. Remission of Diabetes Mellitus (DM), 3. Remission
of Hypertension. A multiple regression analysis was perform in order to identify independent variables that influence these early and late outcomes.
Results: 3166 patients underwent LRYGB or LSG between January 2010 to May 2013 and
completed their follow-up (mean age was 45 years (range 1972); 83.8 % women; mean
body-mass index (BMI) [the weight in kilograms divided by the square of the height in
meters] was 48.45). 89.7 % underwent LRYGB. In 1.7 % of the patients the composite
adverse event outcome was positive. preoperative ASA score was the only independent
variable that influenced the composite adverse event outcome and obstructive sleep apnea
(OSA) was the only one that influenced early readmissions. The independent factors that
influenced %EBWL were age, type of surgery (LRYGB being better than LSG), initial
BMI, initial HbA1c and albumin. Age was found to influence the remission of hypertension,
and the level of initial HbA1c and the presence of OSA were found to be the independent
factors that influence the remission of DM.
Conclusion: The incidence of complications after bariatric surgery is low and can be
predicted by the patients ASA score. The patient age seems less significant in the risk
assessment and should not be used to exclude patients who may still experience significant
benefit from bariatric surgery.

Introduction: Obesity is a worldwide epidemic associated to multiple comorbidities. Diet

and exercise are poorly effective with not long lasting results.
Bariatric surgical procedures are effective but still associated to major complications
however with a low mortality rate.
There is a need for less invasive weight loss procedures and devices such as endoscopic
intrgastric ballon as an alternative to bariatric surgery.
Methods: We present a 2 years experience of endoscopic intragastric ballon placement
(BIB Allergan Inc, Irvine, Calif) performed in a total of 59 patients and done in a day care
setting.
Results:Median follow up of 12 months
BIB removed at 6 months
Short term weight loss range 14 to 18 kg
Weight loss sustained at 12 months 48 %
20 % of patients fail to achieve significance weight loss
No major complications presented in this series
Conclusions: The endoscopic intragastric ballon is thought to induced early satiety by
partially filling the stomach; as presented in this case series results, this is a promising
alternative of weight loss in a growing public health problem.
Long term data on the safety, efficacy and durability of endoluminal bariatric procedures
are needed.

P471

P473

Outcomes of Sleeve Gastrectomy in the Pre- and PostMenopausal Population

Outcomes of Swallowable Intragastric Balloon (Obalon)

as a Treatment Modality for the Overweight And Obese.

Cici Zhang, MD, Lucy Martinek, MD, Yael Marks, MD, Julio
Teixeira, MD, Lenox Hill Hopsital

Salman Al Sabah, Dr, Nourah Alsharqawi, Dr, Ahmed Al Mulla,

Dr, Al Amiri

Introduction: Obesity continues to be a challenging public health dilemma and bariatric

surgery remains an effective treatment modality for long-term weight loss. Sleeve gastrectomy (SG) has gained recent popularity for its feasibility and encouraging results.
Studies have suggested that women over 65 had inferior outcome due to decreased physiological reserve. However, the post-menopausal population remains a largely unstudied
group. The purpose of our study was to determine whether a womans menopausal status
affects weight loss after undergoing SG.
Methods: A retrospective review of 115 patients undergoing laparoscopic SG from
December 2013 through August 2015 was performed. Of these, 18 (15.6 %) were postmenopausal and 13 (11.3 %) were men. 72 (62 %) had 6 week follow up and only 25
(34 %) presented for follow up at 6 months. Outcomes of short-term and medium-term
weight loss (6 weeks and 6 months) for pre- and post-menopausal women were analyzed.
Results: Our results included total percent weight loss between men and women and also
compared pre-menopausal to post-menopausal women. A paired t-test was performed
which demonstrated total percent weight loss for men at 6 weeks was 9.66 % (2.2 %),
and 23.5 % (4.13 %) at 6 months, which is comparable to previous studies. For premenopausal women, 6 week weight loss percentage was 9.1 % (+/-3.14) and 21.1 % (+/4.18) at 6 months compared to post-menopausal women who lost 10.3 % (+/- 3.5) and
22 % (+/- 6.65) at 6 weeks and 6 months. The total weight loss for all patients was 9.35 %
(+/- 3.28) at 6 weeks, 22.3 % (+/- 5.83) at 6 months, respectively. A p-value of 0.18 was
demonstrated for pre- vs. post-menopausal women at 6 weeks postoperatively.
Conclusion: In our analysis, there was no significant difference in short-term and mediumterm total percent weight loss in pre- vs. post-menopausal women who underwent SG.
Further studies are required to evaluate long-term weight loss between these two groups, as
well as on hormonal effects of SG in the pre- and post- menopausal population.

Introduction: The Obalon is a new intra-gastric balloon, which involves a self-inflating

balloon after swallowing the Obalon capsule. This eliminates the necessity for an endoscopy for insertion. This new device is placed for a 12 week period and extracted via
endoscopy. This study aims at evaluating the efficacy and safety of the Obalon.
Methods and Procedures: A retrospective analysis was performed on a total of 58 patients
that underwent Obalon insertion and removal from December 2014 to July 2015. Data
included weight, Body Mass Index (BMI) and complication rate.
Results: 58 Kuwaiti patients underwent Obalon insertion, of which the mean age was 36
(1566) and 43 (80 %) were females. Mean pre-procedure weight and BMI were 87 kg and
33, respectively. A total of 54 out of 58 attempts (93 %) to swallow the balloon were
successful. All patients were followed up by a dietician and received two Obalons. There
was a significant mean Weight loss of 1.4 kg, 0.3 kg and 0.3 kg at one month, two months
and three months, respectively (p-value \ 0.001). After removal of the Obalon, a mean
weight loss of 4 kg and a BMI of 31 were documented. Of the 58 patients, two patients
(4 %) achieved a weight loss of more than 10 kg. A total of two patients (4 %) removed the
Obalon prior to completion of the 12 weeks due to nausea and epigastric pain and three
patients lost follow up.
Conclusion: The Obalon is feasible and safe. A significant mean weight loss at months
one, two and three was noted. However, larger prospective studies are needed and the role
of adding a third Obalon should be further investigated.

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P474

P476

Venous Thromboembolism Prophylaxis in Bariatric Patients:

What is the Right Dose? A Quality Improvement Project.

Bariatric Operative Reporting: Perceptions of Quality Amongst

Canadian Bariatric Surgeons

Taryn Hassinger, MD1, Tjasa Hranjec, MD, MS2, Peter Hallowell,

MD1, Bruce Schirmer, MD1, Sara Hennessy, MD2, 1University
of Virginia, 2UT Southwestern

Shannon E Stogryn, MBBS, Krista Hardy, MSc, MD, FRCSC, FACS,

Ashley Vergis, MMEd, MD, FRCSC, FACS, University of Manitoba

Introduction: Morbidly obese patients undergoing bariatric surgery are at significantly increased risk of
venous thromboembolic events (VTE). Standardized weight-based dosing of low molecular weight heparin
(LMWH) has been demonstrated to decrease incidence of VTE events. However, it is unclear if current
dosing regimens are adequate. We aimed to determine if the current LMWH regimen establishes sufficient
anti-Xa activity to provide effective prophylactic anticoagulation after bariatric surgery.
Methods and Procedures: Between October 2014 and September 2015, a quality improvement project was
conducted involving patients undergoing bariatric surgery at a single institution. Sleeve gastrectomy and
Roux-en-Y gastric bypass patients were divided into two groups: Light group (\300 pounds) and Heavy
group ([300 pounds). All patients received weight-based prophylactic LMWH. Anti-Xa activity, with a goal
of 0.20.4 U/mL, was measured after administration of the third dose. Comorbidities, anti-Xa activity, and
post-operative VTE events and bleeding were compared by univariate analysis.
Results: A total of 50 patients were identified, with 21 patients in the Light group and 29 patients in the
Heavy group. The two groups were equivalent in demographics and comorbidities aside from gender and
hypertension. There was no significant difference in type of procedure between the two groups. Twenty-four
patients (48 %) had a sub-therapeutic anti-Xa level, with no significant difference between groups. Within a
30-day post-operative follow up period, there were five incidents of post-operative bleeding requiring
transfusion and one identified VTE event (Table 1).
Conclusions: There was no significant difference detected in anti-Xa levels between the Heavy and Light
groups. However, nearly half of the patients had inadequate anti-Xa levels after prophylaxis with LMWH.
Therefore, the current VTE prophylaxis algorithm in the morbidly obese undergoing bariatric surgery may
be inadequate. A large prospective study will be required to establish the clinical significance of low anti-Xa
levels in bariatric surgery as well as to monitor the efficacy and safety of current prophylactic anticoagulation regimens.

Table 1

Pertinent demographics and post-operative outcomes

Introduction: Our objective was to evaluate the perceptions of Canadian bariatric surgeons regarding the
quality of operative reporting in bariatric surgery and if there is a potential need for improvement. Additionally, we aimed to assess opinions on the quality and prospective utility of synoptic operative reporting
for bariatric surgical procedures.
Methods and Procedures: A survey was distributed via a secure web based platform to identified active
bariatric surgeons across Canada. Our aim was to have representation from every Canadian province/
territory currently performing laparoscopic bariatric surgical procedures. Demographic information was
gathered including training and practice patterns of current bariatric surgeons. A modification of the validated Structured Assessment Format for Evaluating Operative Reports (SAFE-OR) was used to evaluate the
impression of the quality of narrative dictations for bariatric surgery on anchored 5-point Likert scales. This
was additionally used to assess the quality of synoptic operative reports and gauge their potential to improve
surgical documentation. Free text fields were provided to allow participant elaboration of opinions and
feedback. Comments were collated and reported as themes.
Results: 34 Canadian bariatric surgeons were invited to participate in the web-based survey. Seventy one
percent (24/34) completed the survey. We achieved representation of academic, community, and tertiary
care surgeons across Canada. The most commonly performed procedures were roux en Y gastric bypass
(RYGB) and sleeve gastrectomy (SG) (95.8 % and 100.0 % respectively). 70.8 % currently perform a
traditional narrative operative report and 20.8 % perform a narrative operative report from a template. The
weighted average SAFE-OR assessment scores of narrative dictations for bariatric procedures by surgeons
and trainees were neutral (28.0/40 and 27.5/45 respectively). The lowest scoring items were the description
of indications for surgeons (2.9/5) and succinctness and readability for trainees (2.8 and 2.5
respectively). 12.0 % of respondents acknowledged having experienced a situation where inaccurate
operative reporting had led to poor patient care. Opinions consistently reflected the need for an immediately
generated, standardized, template-based report to improve the quality and accessibility of operative documentation. The group agreed that synoptic reports would be beneficial to improving operative reporting for
bariatric surgery (weighted average 3.3/5). Finally, feedback suggested the reproducible nature of bariatric
procedures lends an inherent suitability to a synoptic format.
Conclusion: Our evaluation of bariatric surgeons demonstrated a perception of mediocre quality of narrative
dictations that could potentially lead to poor patient care. There is desire to create a high quality, validated,
synoptic operative report to address these shortcomings.

P477
Total Weight Loss as the Outcome Measure of Choice After Roux
en-Y-Gastric Bypass

P475
Low Morbidity and Zero In-Hospital Mortality In 1232 Gastric
Bypasses in a Teaching Hospital
John Hwang, MD, Thomas Schnelldorfer, MD, David Brams, MD,
Dmitry Nepomnayshy, MD, Lahey Hospital
BACKGROUND: Although gastric bypass has become increasingly safe, every bariatric program should
strive for zero mortalities. We present a protocol for Roux-en-Y gastric bypass (GB) which has resulted in
zero mortality in 1232 consecutive operations.
Methods: Four different surgeons performed 1232 consecutive primary Roux-en-Y GB procedures. 79.4 %
of patients were female. Average initial BMI was 45.51. Average age was 43. Comorbidities included
diabetes (25.4 %), hypertension (45.5 %), sleep apnea (37.5 %), and reflux (47.6 %). All patients undergo
stringent screening and lifestyle modification classes and a weight loss requirement of 510 % of their body
weight. Patients who are unable to follow healthy lifestyle modifications are not offered surgery. After trying
different techniques during our learning curve, all surgeons standardized their technique to a linear stapled,
antecolic gastro-jejunostomy with a stapled enteric anastomoses. All suturing is performed free-hand. All
fellows achieve proficiency in specific suturing skills in the simulation lab before performing surgery.
Performance of the case is transitioned from attending to trainee in a standardized fashion, starting with
small bowel anastomosis, then gastric transection, second layer of enterotomy closure, first layer of
enterotomy closure and finally mesenteric defect closure until the trainee performs the entire case.
Results: There were no in-hospital deaths during the thirty day postoperative period. There was one patient
who died due to an unrelated cause: a ruptured cerebral aneurysm. Overall readmissions occurred at 6.3 %
and reoperation occurred at 1.4 %.
Conclusions: We report one of the highest single center case series for GB without an in-hospital mortality
at a teaching hospital where trainees perform the procedure. We feel that a combination of patient selection
and preparation, trainee preparation and surgical technique contribute to these results and should be considered by other teaching hospitals to minimize complication rates for gastric bypass surgery.

Mena Boules, MD1, Ricard Corcelles, MD, PhD2, Dvir Froylich,

MD1, Amani Hag, MD1, Zhamak Khorgami, MD1, Bartolome
Burguera, MD1, Matthew Kroh, MD1, Phillip Schauer, MD1, Stacy
Brethauer, MD1, 1Cleveland Clinic, 2Foundation Clinic
for Biomedical Research, Hospital Clinic of Barcelona, University
of Barcelona
Background: Currently, there is no agreement on the best method to describe weight loss (WL) after
bariatric surgery. The aim of this study is to evaluate short-term outcomes using percent of total body weight
loss (%TWL).
Methods: A single-institution retrospective study of 2,420 patients undergoing Roux-en-Y gastric bypass
(RYGB) was performed. Suboptimal WL was defined as %TWL \ 20 % at 12 months.
Results: Mean preoperative BMI was 46.8 7.8 kg/m2. 12 months post-operatively, a mean reduction of
14.1 kg/m2 units of body mass index (BMI), 30.0 8.5 % TWL, and 68.5 22.9 % EWL. At 6 and
12 months post-RYGB, mean BMI and %EWL significantly improved for all 60 baseline BMI groups
(p \ 0.01, BMI; p = 0.01, %EWL), whereas mean %TWL was not significantly different among baseline
BMI groups (p = 0.9). The regression analysis between each metric outcome and preoperative BMI
demonstrated that preoperative BMI did not significantly correlate with %TWL at 1 year (r = 0.04,
p = 0.3). On the contrary, pre-operative BMI was strongly but negatively associated with the %EWL
(r = -0.52,65 p \ 0.01) and positively associated with the BMI units lost at 1 year (r = 0.56, p \ 0.01). In
total, 11.3 % of subjects achieved \20 %TWL at 12 months and were considered as suboptimal WL
patients.
Conclusion: The results of our study confirm that %TWL is a compelling metric when reporting WL due to
less likelihood of being influenced by pre-operative BMI. Importantly, 11 % of patients displayed suboptimal WL during the in the first year after RYGB based on our definition.

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P478

P480

Diagnostic Utility of Ct scans in Detecting Internal Hernias

after Laparoscopic Roux-en-Y Gastric Bypass

10-Years Results of Sleeve Gatsrectomy as Compared to Roux en

Y Gastric Bypass in Patients with Morbid Obesity a Case Control
Study

Mohammad Farukhi, MD, Benjamin Clapp, MD, Alan Tyroch, MD,

Jayanta Gupta, MD, PhD, Christopher Dodoo, MS, Michael
Mattingly, BS, Texas Tech Paul F Foster School of Medicine
Background: Gastric bypass patients can present in the acute setting with clinical symptoms of obstruction such as abdominal pain, nausea, and vomiting. Internal hernias (IH) are
an important cause of small bowel obstruction (SBO). Identifying the cause of SBO on
radiographic imaging is crucial as internal hernias are a known surgical emergency.
Study Design: Data from laparoscopic Roux-en-Y gastric bypass patients that presented
with signs and symptoms of SBO from 2010 to 2014 were retrospectively analyzed. All
patients with obstruction-like complaints that had a CT scan on admission and were taken to
the operating room for diagnostic laparoscopy were included.
Results: Obstruction was found on CT in 34 patients after laparoscopic Roux-en-Y gastric
bypass. Six of the 34 patients were more specifically preoperatively diagnosed with IH by
CT. All patients underwent surgical evaluation. Causes of SBO on operative findings
included internal hernias (n = 14), adhesions (n = 17), jejunojejunostomy stenosis
(n = 2), and other (n = 1). Four of the 6 internal hernias found on CT had consistent
findings in the OR. Sensitivity of internal hernia on CT scans was found to be 28.6 % with
specificity of 90.0 %.
Conclusions: Detecting internal hernias after gastric bypass remains a challenge. We found
CT to have a low sensitivity of 28.5 % but a high specificity of 90 % for detecting internal
hernias in patients who present with signs of acute obstruction after laparoscopic gastric
bypass. Laparoscopic exploration remains the most appropriate and definitive treatment for
this complication.

Elie K Chouillard, Ronald Daher, MD, Mariam Alahmadi, MD,

Bashaer Alkandari, MD, Elias Chahine, Alain Fajardy, MD, PARIS
POISSY MEDICAL CENTER
Introduction: Bariatric surgery is an effective therapy to induce long-term weight loss and
control comorbidities in morbidly obese patients. We have been performing laparoscopic
Roux-en-Y Gastric Bypass (RYGB) since 2001. Laparoscopic Sleeve Gastrectomy (SG),
introduced in 2004 as a primary bariatric procedure, is currently the most commonly
performed bariatric procedure in France. The aim of this study is to evaluate the 10-years
results of SG for patients with morbid obesity as compared to RYGB in a case control
study.
Methods and Procedures: We performed the first SG as a primary bariatric procedure in
February 2004. After the accomplishment of the initial learning curve period, we started
enrolling the patients in a prospective database. The aim of this study is to assess the longterm results of SG in patients who completed 10 years follow up. Subsequently, we performed a case control study by matching patients with those who had a RYGB during the
same period.
Between December 2004 and August 2005, 26 patients had SG, of whom 4 were lost to
follow up (15.4 %). During the same study period, 214 patients underwent RYGB of whom
22 were matched according to criteria including, age, sex, body mass index (BMI), and the
type of comorbidities.
The primary endpoint was the 10-year percentage of excess weight loss (EWL). Secondary
endpoints comprised resolution of comorbidities, reoperation for complications, revision,
and quality of life (QOL) assessment.
Results: Average 10-years EWL was 48.8 % in the SG group and 61.8 % in the RYGB
group (p \ 0.05). Three patients (13.6 %) in the SG group and 5 patients (22.7 %) in the
RYGB were reoperated for complications (i.e., cholelithiasis, intestinal obstruction, perforated ulcer, stenosis) (p \ 0.05). In the SG group, 5 patients had revisions for reflux or
insufficient weight loss (22.7 %). One patient who had RYGB had revision for weight loss
insufficiency (4.5 %) (p \ 0.05). Resolution of comorbidities as well QOL assessment was
comparable in both groups (p [ 0.05).
Conclusions: The analysis of the 10-years results in this small case control study shows that
SG is associated to significantly less weight loss as compared to the RYGB. However,
reoperation for complications is higher after RYGB.

P479

P481

Bariatric Surgery Improves Quality of Life and Maintains

Nutritional Status of Older Obese Patients

Comparing Stenosis Rate of Gastrojejunal Anastomosis Between

21-mm and 25-mm Circular Stapler in Laparoscopic Roux-en-Y
Gastric Bypass: A Preliminary Report of Randomized Clinical
Trial

Elie Chouillard1, Ronald Daher, MD1, Jean Biagini, MD2, 1PARIS

POISSY MEDICAL CENTER, 2SAINT JOSEPH MEDICAL
CENTER
Introduction: Bariatric surgery is being safely performed in older patients. Quality of life
and aggravation of sarcopenic obesity, however, have never been assessed in this subgroup
of patients. This retrospective study aims to evaluate quality of life of older obese patients
after surgery and to compare variations of their nutritional parameters to those of younger
patients.
Methods and Procedures: Seventy-nine patients older than 60 years (Group 1) were
matched 1:2 with 158 patients younger than 50 years (Group 2) for comparison of nutritional parameters. A modified Impact of Weight on Quality Of Life (IWQOL) questionnaire
was filled by all included patients, at the one-year check-up.
Results: The preoperative serum albumin and prealbumin levels were comparable between
the two groups. Albumin values regained preoperative levels at six months in both groups
intergroup comparison showed no significant difference. The serum prealbumin levels
reached back the preoperative values at 12 and 6 months in Groups 1 and 2, respectively.
Values were significantly lower in Group 1 comparatively to Group 2 at three and six
months (0.18 versus 0.19; p = 0.04 and 0.20 versus 0.21; p = 0.03, respectively) but not at
one year. Sixty-nine patients (87.3 %) gave a total of 1860 answers in the modified
IWQOL. Among them, 181 (9.7 %) and 1422 (76.5 %) were in favour of mild and marked
improvements, respectively.
Conclusions: Bariatric surgery improves quality of life of older obese patients with no
compromise of their nutritional status. In the lack of precise recommendations, this represents a major argument that may serve to the preoperative assessment of such patients.

123

Jakrapan Wittayapairoch, MD1, Pakkavuth Chanswangphuvana,

MD2, Ajjana Techagampuch, MD2, Narong Boonyagard, MD2,
Pondech Vichajarn, MD2, Rapheephat Tanomphetsanga, MD2, Krit
Kitisin, MD2, Suppa-ut Pungpapong, MD2, Chadin Tharavej, MD2,
Patpong Navicharern, MD2, Suthep Udomsawaengsup, MD2,
1
Department of Surgery, Faculty of Medicine, Khon Kaen University,
Khon Kaen, Thailand, 2Department of Surgery, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand.
Introduction: Gastrojejunal anastomosis stenosis is the most common early complication
in Laparoscopic Roux-en-y Gastric bypass (LRYGB), The stenosis rate appears to be
correlated with the size of circular stapler.
Method and Procedures: Morbid obese patients in King Chulalongkorn memorial hospital, scheduled for LRYGB, were randomized to undergo gastrojejunal anastomosis (GJA)
by 21-mm or 25-mm circular-stapler. Stenosis of GJA is defined as patient complaints
vomiting and/or dysphagia with liquid or meal leading to endoscope 12 weeks postoperatively. A stenosis was confirmed by inability to pass a gastroscope through GJA. Incidence
of stenosis of GJA, %EWL at 12 months after surgery, perioperative complications and
mortality were evaluated.
Results: 68 patients were randomized to 35 in 21-mm group and 33 in 25 group. There was
no different in demographic data. Stenosis of GJA was report in 5 patients of 21-mm group
and 2 patients of 25-mm group (14.28 % vs 6.06 % respectively, p = 0.26), %EWL at
12 months was similar between both groups.
Conclusions: In this preliminary report 21-mm and 25-mm circular stapled GJA are safe
and effective for LRGB. There was no significant rate of stenosis after GJA. However longterm follow-up is mandatory to address effect of size of circular stapler on stenosis rate and
weight loss.

Surg Endosc (2016) 30:S325S500

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P482

P484

Improvement of Comorbidities After Revisional Robotic Rouxen-Y Gastric Bypass Surgery

Super-Super Obesity: Early Outcome After Laparoscopic Sleeve

Gastrectomy And Gastric Bypass in Observational Study

Raquel Gonzalez-Heredia, MD, PhD, Lisa Sanchez-Johnsen, PhD,

Janine Devicais, Enrique Elli, MD, FACS, UIC

Rapheephat Tanompetsanga, MD, Pondech Vichajarn, MD, Narong

Boonyagard, Jakrapan Wittayapairoch, Krit Kitisin, Suppa-ut
Pungpapong, AsstProf, Chadin Tharavej, AssocProf, Patpong
Navicharern, AssocProf, Suthep Udomsawaengsup, assocProf, King
Chulalongkorn Memorial Hospital

Introduction: Bariatric revision surgery is sometimes required due to inadequate or insufficient

weight loss, the continuous onset of comorbidities and long-term complications regarding the prior
bariatric procedure. The aim of this study was to examine the remission or improvement of medical
comorbidities after revisional RYGB surgery
Material and Methods: This is a retrospective study of patients who underwent a revisional Roboticassisted Roux-en-Y gastric bypass (RYGB) surgery from January 2008 to June 2014 at the University of
Illinois Health and Sciences System.
Results: A total of 32 female patients underwent revisional RYGB revision surgery as a reoperation from
adjustable laproscopic gastric band (n = 16) or sleeve gastrectomy (n = 11) or previous gastric bypass
(n = 5). Mean BMI was 40 10.6 kg/m2. The prevalence of comorbidities was as follows: HTN-43.75 %,
T2DM-28.1 % and DLP-25 % prior the revisional surgery. The mean operative time for the revision was
226 45.3 minutes. Average length of hospitalization was 3 days. No post-operative complications or
mortalities were recorded. Of those patients who had a pre-revision surgery medical comorbidity, their
comorbidities improved in the following way: 64.2 % (9/14) for HTN, 77.8 % (7/9) in T2DM, and 62.5 %
in DLP. In the patients who underwent revision surgery due to weight loss failure (n = 20), the mean excess
weight loss (EWL) was 39.2 % at 6 months (n = 11), 53.8 % at 1 year (n = 13) and 60.7 % at 2 years
(n = 6).
Conclusions: Revisional RYGB surgery was associated with significant improvements in comorbities and
weight loss from pre-revision to post-revision surgery. This study provides initial support for RYGB to be
used as a revisional surgery.

Introduction: morbid obesity is the second most common cause of preventable death in worldwide.
Bariatric surgery has been proven the effectiveness in weight reducing and comorbidity resolution. However
performing bariatric surgery in super-super obesity (BMI [ 60 kg/m2) is very difficult because of huge liver
and large volume of visceral fat. There has been no conclusion of best technique for these patient. Therefore
this study was designed for evaluation the outcome of bariatric surgery in super-super obesity.
Patient and Methods: Observational study comparing data of 68 super-super obesity (BMI [ 60 kg/m2)
submitted to laparoscopic sleeve gastrectomy (LSG, n = 50) and laparoscopic Roux en Y gastric bypass
(LRYGB, n = 18) between 2005 - 2015 at King Chulalongkorn Memorial Hospital. The primary objective
was to analyze baseline demographics data, body mass index (BMI), %excess weight (%EWL), comorbidity
and post operative complication. Secondarily, BMI and %EWL was analyzed and compared between both
operation (LSG vs. LRYGB) in first year
Results: There was 46 male and 22 female undergoing to do bariatric surgery. Mean of age was
31 1 years (range 1153 years) and the most associated co-morbidity in those patients was OSA (82 %)
and HT (57 %). Both group were comparable of BMI (70.31 + 8.0 kg/m2 in LSG and 69.46 + 6.5 kg/m2 in
LRYGB;p = 0.685). There were 2 cases of major complications (post operative bleeding in 1 patient and
another one was post operative leakage) that have to urgent reintervention. No mortality in this
study. %EWL in duration of 1,3,6,9,12 months was not difference between LSG and LRYGB;15.7 5.61
vs 18.5 9.83 kg/m2 (p = 0.189) at 1 month,25.6 7.2 vs 26.56 11 kg/m2 (p = 0.712) at 3 months,
34.94 9.1 vs 39.3 12.76 kg/m2 (p = 0.185) at 6 month, 42.19 10.56 vs 43.45 8.19 kg/m2
(p = 0.733) at 9 months and 46.1 12.6 vs 52.41 16.06 kg/m2(p = 0.192) at 12 months.
Conclusion: Both LSG and LRYGB was safe and effectiveness to achieve %EWL in patient with supersuper obesity when comparing in first year. LSG is more simple and comfortable than LRYGB for bariatric
surgeons to do operation in patient with difficult situation of these heavy weigh patient such as huge liver
and large volume of visceral fat. However long term follow up data of %EWL and resolution of comorbidity
in both operation has been needed.

P483

P485

First Adolescent Bariatric Center of Excellence: Guidelines,

Procedures, Pitfalls and Solutions

Predictive Factors of Type 2 Diabetes Remission After Bariatric

Surgery: A Multivariate Analysis

Ragui W Sadek, MD, FACS1, Andrew M Wassef, BA2, 1Robert

Wood Johnson University Hospital, 2Rutgers Robert Wood Johnson
Medical School

Jerry T Dang, BSc, MD1, Caroline Sheppard, BSc1, David H Kim,

BSc2, Xinzhe Shi, MPH, MMSc, BSc3, Chris de Gara, MB, MS,
FRCS, Ed, Eng,, C, FACS3, Shahzeer Karmali, MD, FRCSC, FACS3,
Daniel W Birch, MSc, MD, FRCSC, FACS3, 1Department of Surgery,
University of Alberta, Edmonton, Alberta, Canada, 2Faculty
of Medicine and Dentistry, University of Alberta, Edmonton, Alberta,
Canada, 3Centre for the Advancement of Minimally Invasive Surgery
(CAMIS), Royal Alexandra Hospital, Edmonton, Alberta, Canada

Background: Adolescent obesity, a seemingly nonexistent occurrence to children of the 1960s, has
developed into one of the most chronic diseases plaguing children today. Comorbidities commonly associated with adult morbid obesity, such as type II diabetes mellitus, hypertension, and dyslipidemia, are now
diseases associated with a much younger subset of morbidly obese patients (1521 YOA). With the
astronomical quadrupled growth of adolescent obesity in just 30 years time, consideration for more invasive
treatments such as surgical management of adolescent obesity, has been tested, tried, and found wanting. We
present the case of the first established Adolescent Bariatric Center of Excellence in the United States. The
following review discusses the epidemiology of adolescent obesity, markers for operative therapy, optimal
surgical procedures for adolescent weight loss, multidisciplinary management for this unique patient population, and surprising outcomes of our program.
Methods: The following study consists of forty-one (n = 41) adolescent bariatric patients (Male = 26,
Female = 15) with ages ranging from 1521 years of age who received sleeve gastrectomy. All patients
received weight check and blood workup and general examination pre-operatively and post operatively at
1 week, 1 month, 3 month, 6 months and 1 year. All patients were enrolled in the Adolescent Bariatric
Center of Excellence at Bristol Meyer Squibb Childrens Hospital and subject to all requirements including
nutrition, exercise, and support group regimens. Patients were accessed for excess weight loss, resolution of
comorbidities, complications, vitamin deficiencies, and general quality of life.
Results:

Male

Female

Excess weight loss

83 %

80 %

Resolution of T2DM

100 %

95 %

Resolution of hyperlipidimia

100 %

None

Resolution of joint pain

100 %

100 %

Complication Rate

0%

0%

Vitamin Deficiency

0%

0%

Quality of life increase after surgery

60.5 %

58.5 %

(110 before/110 after)-100

Conclusions: Surgery for obesity in adolescents has particular risks and benefits that must be accounted for
when considering an invasive approach due to their unique physiological, psychological and emotional
needs. As such, reasonable guidelines are necessary to ensure successful/safe weight loss in adolescent
patients.

Introduction: The aim of this study is to identify predictive factors for remission of type 2 diabetes (T2DM)
after bariatric surgery. Bariatric surgery has been shown to induce diabetic remission in some severely obese
patients. However, patients respond differently to surgery. Some patients achieve complete remission, while
others remain diabetic. There is limited data on the factors that predict remission and previous research has
identified preoperative factors such as time from diabetes diagnosis and Hba1c. As such, identifying predictors of diabetic remission after bariatric surgery is useful to prognosticate and decide which diabetic
patients will benefit most from bariatric surgery.
Methods and Procedures: A retrospective review of all T2DM patients undergoing laparoscopic
adjustable gastric band (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve
gastrectomy (LSG), from January 2008 to July 2014 was performed. Patient preoperative and postoperative
clinical and biochemical data were collected and analyzed using univariate and multivariate logistic
regression analysis to identify preoperative predictive factors of diabetic remission. Diabetic remission was
defined as: absence of hypoglycemic medications, fasting blood glucose \7 mmol/L and HbA1c \6.5 %.
Results: Two hundred and forty-one T2DM patients underwent bariatric surgery. Twelve were excluded
because of missing clinical or biochemical data. Two hundred and twenty-nine were included in logistic
regression analysis with 46.2 % (106) of patients achieving diabetic remission at one year.
In univariate analysis, patients with diabetic remission were younger, using less preoperative insulin and oral
hypoglycemics and were less frequently diagnosed with hypertension than those without remission. They
also had lower HbA1c, fasting blood glucose, creatinine and LDL. Both LRYGB and LSG had higher
remission rates than LAGB, with remission rates of 58.7 %, 39.0 % and 11.5 % for LRYGB, LSG and
LAGB respectively.
Multivariate analysis confirmed that LRYGB had the highest odds of remission (p \ 0.001), while LSG had
second highest (p = 0.035). Additionally, shorter T2DM duration (p = 0.018), less number of preoperative
oral hypoglycemics (p = 0.013) and absence of long-acting insulin (p = 0.018) predicted diabetic remission
in multivariate analysis after controlling for confounders and interactions.
Conclusions: Diabetic remission occurred in 46.2 % of diabetic patients by one year post-bariatric surgery.
Type of bariatric procedure (LRYGB and LSG), more recent diagnosis of T2DM, less preoperative oral
hypoglycemics and absence of long-acting insulin were independent predictors of remission. This potentially helps clinicians in predicting which patients will achieve diabetic remission following bariatric
surgery.

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P486

P488

Improvement in Type II Diabetes Post-Roux-en-Y Gastric Bypass

Surgery

Pulmonary Embolism and Mortality After Laparoscopic

Bariatric Surgery in Patients Using Nuvaring

William Neal, BS, Raquel Gonzalez-Heredia, MD, PhD, Omar Jamil,

BS, Lisa Sanchez-Johnsen, PhD, Enrique Elli, MD, FACS, UIC

Ashish Padnani, MD1, Koji Park, MD1, Ninan Koshy1, James

McGinty, MD1, John Harvey, MD1, Darshak Shah2, 1Mount Sinai St.
Lukes Hospital, 2Mount Sinai Hospital

Introduction: For many obese individuals with type II diabetes, pharmaceutical and lifestyle intervention
alone or in combination are insufficient methods for glycemic control. The purpose of this study was to
determine the percent and number of patients who partially or completely resolved their diabetes postRYGB as measured by HbA1c, fasting plasma glucose (FPG), and pharmaceutical usage.
Material and Methods: This is a retrospective cohort study where 135 patients with type II diabetes were
identified from 324 patients who underwent roux-en-y gastric bypass surgery at the University of Illinois
Hospital & Health Sciences System (Chicago, IL) between June 2008 and June 2015. Partial and complete
remissions were based upon American Diabetes Association criteria: Partial remission was defined as HbA1c
\6.5 % or FPG 100125 mg/dL; Complete remission was defined as HbA1c\ .7 % or FPG \ 100 mg/dL.
Glucose levels were classified as follows: Normal glucose (\100 mg/dL), pre-diabetes (100125 mg/dL)
and diabetes ([125 mg/dL). This study also included decreased or discontinued medications as partial and
complete remission, respectively. Data was analyzed using SPSS statistical software and p values \0.05
were considered statistically significant.
Results: In regards to HbA1c, 29 % of the diabetic patients achieved partial remission by 3-months. The
pre-operative mean HbA1c was 7.8 %, recorded by 71 % (n = 96) of patients. By three-months, 21 %
(n = 28) achieved partial remission (\6.5 %) with a mean HbA1c of 6.2 % and at 12-months the mean
HbA1c was 5.9 %. Eighty-six patients (64 %) were lost to follow-up over the 12-month span. As expected,
pre-operative mean FPG for non-diabetics was normal (96.9 mg/dL), while the diabetic mean FPG was
147 mg/dL. Three months post-RYGB, diabetics (n = 39) reported a 21 % decrease mean FPG to
116.6 mg/dL into the pre-diabetic range. Additional data was gathered for decreases or discontinuations in
medications past three months. In diabetic patients, 83.7 % (n = 113) followed up to record pharmaceutical
changes during post-operative visits starting at three months. Results revealed that at any follow-up beyond
three months post-surgery, 35.4 % (n = 40) achieved partial remission by decreasing at least one medication while 42 % (n = 47) achieved complete resolution by discontinuing at least one medication.
Conclusions: Previous research has demonstrated that partial resolution of type II diabetes and decreases in
HbA1c, glucose and medications are reasonable outcomes to expect post-surgery. Additional studies with
larger sample sizes and longer follow-up are needed to further examine partial and complete remission of
diabetes post RYGB surgery.

Introduction: Estrogen containing hormonal contraceptives have been known to have risk of venous
thromboembolism (VTE). The risk is much higher in obese patients undergoing laparoscopic bariatric
surgery. NuvaRing is a contraceptive vaginal ring containing etonogestrel and ethinylestradiol, inserted in
vagina once a month. Some studies show significantly higher risk of VTE compared to oral contraceptives.
We present two cases of mortalities from pulmonary embolism (PE) in patients undergoing laparoscopic
sleeve gastrectomy. Both patients used NuvaRing preoperatively and continued it postoperatively. They
had no other known risk factors.
Case 1: 23 years old female patient with BMI of 48 kg/m2, past medical history of asthma underwent an
elective laparoscopic sleeve gastrectomy. She received unfractionated heparin (UFH) subcutaneously preoperatively and sequential compression devices (SCDs) for VTE prophylaxis, and were continued
postoperatively. Her postoperative course was unremarkable. She was discharged home on postoperative
day (POD)#2. POD#10 she had an episode of syncope and was taken to outside hospital where she was
found to have lower extremity VTE and PE. She was started on anticoagulation. She became hemodynamically unstable and expired on POD#11.
Case 2: 21 years old female patient with BMI of 42.75 kg/m2 and no other significant past medical history
underwent elective laparoscopic sleeve gastrectomy. She received unfractionated heparin (UFH) subcutaneously preoperatively and SCDs for VTE prophylaxis, and were continued postoperatively. Her
postoperative course was unremarkable. She was discharged home on POD#2. Patient presented back to
emergency room (ER) on POD#5 with epigastric discomfort. She was not dyspneic and her vital signs were
stable. An ultrasound of abdomen obtained was unremarkable. She was discharged home without surgical
consultation. POD#6 patient developed severe shortness of breath. She was taken to outside hospital and
found to have massive PE. She was hemodynamically unstable and expired the same day.
Conclusion: NuvaRing poses a unique challenge. Since its not daily administered medication, patients
often forget to mention about it during preoperative assessment. It is relatively new and there is minimal
literature about its side effects and safety profile in obese patients undergoing laparoscopic bariatric surgery.
So it is important to do careful screening preoperatively. The purpose of this paper is to increase awareness
amongst surgeons about NuvaRing and its potential side effects. Per manufacturer, it is recommended to
discontinue its use for at least 4 weeks before surgery and to not restart it until at least 2 weeks after surgery.

P487
P489
Early Readmission After Laparoscopic Roux-en-Y Gastric
Bypass
Camille D Blackledge, MD, Aerin DeRussy, MPH, Allison Gullick,
MSPH, Richard Stahl, MD, Jayleen Grams, MD, PhD, The University
of Alabama at Birmingham
Background: Bariatric surgery has emerged as an effective and durable treatment for obesity and obesityrelated comorbidities. Postoperative readmissions result in an increase in overall cost and are increasingly
being used as a benchmark for quality of care. The purpose of this study was to examine the risk factors
associated with and reasons for readmission following laparoscopic Roux-en-Y gastric bypass (LRYGB).
Methods: An Institutional Review Board-approved retrospective review was conducted of all patients
undergoing LRYGB at a single institution between 2005 and 2013. Data analyzed included preoperative
demographics and clinical status and 30- and 90-day hospital readmission. Readmission was divided into
early readmission at B 30 days post procedure, and late readmissions at 3190 days post discharge.
Summary Z-Scores were used as a proxy for socioeconomic status when individual characteristics were
unavailable. Univariate and bivariate frequencies were used to describe population characteristics and
factors associated with readmissions. Chi-square tests were used to determine differences among categorical
variables and the Wilcoxon Rank Sums test was used to determine differences among continuous variables
(Table 1).
Results: Of the 652 patients who underwent LRYGB during the study period, the overall rate of readmission
was 4.4 %. Eleven patients had 12 early readmissions, and 15 patients had 17 additional readmissions at
90 days. There were no statistically significant differences in demographics, socioeconomic status, geographical distance, or clinical status between the patients who were readmitted and those who were not. The
reasons for readmission are included below. The diagnoses associated with early readmissions included
undetermined (33.3 %), anastomotic complications (33.3 %), other GI etiology [small bowel obstruction,
portal vein thrombosis, GI bleeding (25 %)], and pneumonia (8.3 %). The diagnoses associated with late
readmissions included anastomotic complications (52.9 %), undetermined etiology (17.6 %), disease
unrelated to bariatric surgery (17.6 %), and biliary complications (11.8 %).
Conclusion: No significant risk factors were associated with readmission after bariatric surgery. Post
discharge nausea, vomiting, and abdominal pain were the most common reasons for readmission following
LRYGB. These symptoms were of an undetermined etiology during the early postoperative period and
indicated anastomotic complications in the late postoperative period. Our results suggest GI symptoms are
the most common reason for readmission after bariatric surgery. Efforts to improve education both preoperatively and at discharge may reduce early readmissions after LRYGB.

Table 1 Reasons for readmissiona

123

Resident Involvement Does Not Increase Complication Rates

in Bariatric Surgery
Collin R Creange, MD, Bradley Schwack, MD, Marina Kurian, MD,
George Fielding, MD, Christine Ren-Fielding, MD, New York
University Medical Center
Introduction: The impact of resident involvement on outcomes after bariatric procedures is not well
understood. Prior studies have demonstrated increased complication rates with resident involvement in
Roux-en-y gastric bypass (RYGB). These studies did not include data for laparoscopic sleeve gastrectomy
(LSG) and laparoscopic adjustable gastric band (LAGB). At our institution, attending surgeons operate with
both residents and physician assistants (PA) interchangeably, thus controlling for surgeon variability. Our
objective was to demonstrate that resident involvement in complex bariatric surgeries does not increase
complication rates when residents and PAs work with the same attending surgeons.
Methods and Procedures: Patients undergoing bariatric procedures at our institution between 3/2012 and
3/2015 were identified using the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database. All patients under 18 years of age were excluded. Cases were stratified into four different
categories- RYGB, LSG, LAGB, and LAGB revision (replacement, removal, or port revision). Data
included patient demographics, comorbidities, length of stay, and 30-day complications. The primary
outcomes of the study were operative time and 30-day overall complication rate. Secondary outcomes
included length of stay, major complications and reoperation rates.
Results: There were 2741 bariatric surgeries performed from 20122015. Of those, 2067 had resident
involvement and 674 had PA involvement. 30-day complication rates for all surgery types, with and without
residents, were 5.3 % and 6.1 %, respectively (p = .45). Complication rates for LSG (p = .716), LAGB
(p = .694), LAGB revision (p = .493), and RYGB (p = .126) were also not significant. Operative duration
for all surgery types was longer with residents (77.0 vs 60.6 min, p \ .0001). Operative duration was longer
with resident involvement for LSG (101.1 vs 76.6 min, p \ .0001), LAGB (51.6 vs 42.4 min, p \ .0001),
and LAGB revision (63.0 vs 51.6 min, p = .007). After risk adjustment, OR time for RYGB was significantly longer as well (134.3 min vs 119.3 min, p = .038). Length of stay was also found to be significantly
increased in the resident group (1.23 vs 1.09 days, p = .0007).
Conclusion: Resident involvement as first assistant in the OR does not increase complication rates in
bariatric surgery. Operative times and length of stay are prolonged, as shown in other studies, but no
difference was seen in complication rates for cases involving a resident and cases involving a dedicated
operative PA. Teaching advanced bariatric surgery techniques to residents is both safe and essential to their
education.

Surg Endosc (2016) 30:S325S500

S453

P490

P492

An Update on Idiopathic Intracranial Hypertension and Bariatric

Surgery: A Systematic Review

Intragastric Balloon for Management of Severe Obesity:

A Systematic Review

Warren Sun1, Noah J Switzer2, Taylor Smart2, Jerry T Dang2,

Richdeep S Gill2, Christopher de Gara2, Daniel Birch2, Shahzeer
Karmali2, 1Faculty of Medicine and Dentistry, University of Alberta,
2
University of Alberta

Ekua Yorke1, Noah J Switzer1, Artan Reso2, Xinzhe Shi1, Christopher

de Gara1, Daniel Birch1, Richdeep S Gill2, Shahzeer Karmali1,
1
University of Alberta, 2University of Calgary

Introduction: We aimed to systematically review the literature to determine the efficacy of bariatric surgery
on Idiopathic Intracranial Hypertension (IIH). Commonly referred to as pseudotumour cerebri, the syndrome
involves increased intracranial pressures with normal cerebral anatomy, with a constellation of classic
symptoms including headache, nausea, visual acuity deficits, pulsatile tinnitus and papilloedema. The link
between IIH and obesity has been well established in the literature, likely through transmitted intra-abdominal pressure to the craniospinal axis. As bariatric surgery remains the only proven treatment modality
for obesity, case reports and case series have pointed to the potential benefit of this type of intervention for
IIH.
Methods and Procedures: A comprehensive search (limited to English and human) of MEDLINE,
EMBASE, SCOPUS, the Cochrane Library, and Web of Science from 1946 to July 2015 was completed.
Title searching was restricted to the following keywords/terms: bariatric surgery/gastric bypass/ gastric
band/ sleeve gastrectomy and intracranial hypertension/pseudotumour cerebri. 120 studies were reviewed
for inclusion into the systematic review.
Results: Twelve primary studies (n = 39) were included in the systematic review. All patients had a
preoperative diagnosis of IIH. Preoperative BMI was 48.55 kg/m2 which improved to 33.67 kg/m2 and
33.94 kg/m2 at 6 and 12 months respectively. Lumbar puncture opening pressures dropping from
403 mmHg pre-operatively to 140 mmHg. Common symptoms of IIH were compared before and after
bariatric surgery respectively: headaches (100 % vs 10 %), visual complaints (62 % vs 44 %), tinnitus
(56 % vs 3 %), papilloedema (62 % vs 8 %).
Conclusion: Bariatric surgery appears to lead to marked improvement in IIH. IIH is not a well publicized
comorbidity of obesity but its presence should be considered as an indication for surgical intervention.

Introduction: We aimed to systematically examine the literature to determine the efficacy and safety of
intragastric balloon therapy for obesity. Minimally Invasive, non-surgical options for weight-loss are
gaining popularity. Specifically, the intragastric balloon (IGB) is an endoscopic procedure where a gastric
space-occupying balloon induces satiety and restricts oral intake. Recently approved by the FDA, the
intragastric balloon can act as a potential bridge therapy prior to definitive bariatric surgery in higher risk
bariatric patients. However, one of the historic complications associated with older models of IGBs were
their unacceptably high complication rates and inconsequential weight-loss.
Methods and Procedures: A comprehensive search (limited to English and human) of MEDLINE,
EMBASE, SCOPUS, the Cochrane Library, and Web of Science from 1946 to July 2015 was completed.
Title searching was restricted to the following keywords/terms: bariatric surgery, gastric bypass, gastric
band, sleeve gastrectomy and intragastric balloon. 570 studies were identified and reviewed based on title
and abstract and 147 studies were reviewed by full paper.
Results: Thirty-seven primary studies (n = 6130) were included in this review. Mean patient age was
38.6 + 4.1 years and mean pre-operative weight and body mass index (BMI) were 126.8 kg + 27.8 and
43.1 kg/m2 + 8.6 respectively. Post-balloon removal at 6 months, mean weight loss, change in BMI, and
excess weight loss (EWL) were 14.6 kg, 4.9 kg/m2, and 33.9 %, respectively. The most common complications were nausea/vomiting (30.5 %), abdominal pain (15.6 %), and gastroesophageal reflux (12.5 %).
Serious complications were rare: mortality (0.1 %), gastric ulcer (0.8 %), gastric perforation (0.1 %) and
balloon migration (0.8 %). Early balloon removal occurred in 7.6 % of patients, most commonly due to
intolerance (47.6 %), balloon deflation (8.9 %), nausea/vomiting (7.9 %), and abdominal pain (7.0 %).
Conclusion: IGB therapy is associated with marked short-term weight loss with limited serious complications. If a patient is able to tolerate the balloon, then IGB may be an important bridging therapy for the
severely obese patient awaiting bariatric surgical intervention.

P491

P493

Is the Robotic Sleeve Gastrectomy Comparable to Laparoscopy:

A Single-Institution Retrospective Review of 376 Cases

Laparoscopic Sleeve Gastrectomy, 200 Cases Without a Leak:

Short-Term Results, Complications and Technical Considerations

Vladimir Davidyuk, MD, Tejinder P Singh, MD, Brian R Binetti,

MD, Daniel J Bonville, DO, Erin Corsini, Albany Medical Center

Asem Ghasoup, MD, FACS1, Turki Al Qurashi, MD1, Mohammed

Widinly, MD1, Omar Sadieh, MD, FACS2, 1Security Forces Hospital
Makkah, 2Saad specialty Hospital

Background: Sleeve gastrectomy has in the past comprised the first part of the duodenal switch procedure,
but now is an established bariatric surgical procedure and has gained in popularity in recent years due to its
safety and efficacy. With the increasing accessibility of robotic technology, outcomes comparing laparoscopic sleeve gastrectomy (LSG) with robotic-assisted sleeve gastrectomy (RSG) are not widely reported or
are equivocal in nature. This investigation aims to determine outcomes of LSG as compared to RSG.
Materials and Methods: This study is a nonrandomized, controlled, retrospective review of 376 patients
who underwent elective minimally invasive sleeve gastrectomy at the Albany Medical Center Hospital from
July 2008 to March 2014. A total of 246 patients underwent laparoscopic sleeve gastrectomy, while 130
underwent robotic sleeve gastrectomy using the da Vinci Surgical System. Patient demographics,
comorbidities, as well as any concurrent procedures were recorded. Results that were collected and analyzed
include: operative time, length of hospital stay, estimated blood loss, mean length of follow-up, excess body
weight loss at 1 year and postoperative complications. Data were analyzed using Stata software with the
help of a statistician. V2 test was used for categorical variables and t-test was used to continuous variables.
P B 0.05 was considered statistically significant.
Results:

Laparoscopic

Robotic

Background: Morbid obesity has become a major health problem in Saudi Arabia. Laparoscopic sleeve
gastrectomy is an accepted method among bariatric surgeons for treating morbidly obese patients with a
reduced rate of complications. We describe results of a single surgeons experience in our institution with
LSG revealing a low complication rate and describing the surgical technique.
Methods: LSG was performed in 200 consecutive patients from June 2014 to June 2015.
A technique is described where all operations were performed with avoiding strictures at the incisura
angularis and stapling close to the esophagus at the angle of His.
All operations performed used over sewing of the staple line.
Results: Follow-up data was collected for all patients at 12 weeks. A total complication rate of 4.1 % and a
1.3 % 30-day readmission rate were observed. No leaks occurred in any of the 200 patients. The most
common complications were nausea and vomiting with dehydration. The percentages of excess weight loss
were 38.3, 57.8 and 64.4 with a follow-up of 68 %, 61 %, and 47 % at 6 months.
Conclusion: LSG can be performed for treatment of morbid obesity with a low complication rate. Surgeons
performing LSG should minimize the risk of creating strictures at the incisura angularis and stapling near the
esophagus at the angle of His.

P value

Excess Weight loss at 1 yr (%)

61.7

62.8

0.75

Hospital length of stay (days)

3.04

2.87

0.48

Estimated blood loss (ml)

54.5

33.7

0.0010

Operative time (minutes)

113

110

0.55

Total complications n (%)

21(8.5 %)

8(6.2 %)

0.41

Demographic data between the two groups were similar. The mean length of stay, operative
time and excess weight loss at 1 year were similar between both groups. The estimated
blood loss was statistically significant, however the difference is not clinically significant.
The percentage of patients with intraoperative and postoperative complications for each
type of procedure is similar. In this study operative time was recorded from time-out until
skin closure. In our study, unlike in previous reports the operative time was the same for
both types of cases.
Conclusion: The operative time and complications are similar between both groups.
Robotic sleeve gastrectomy has comparable outcomes to laparoscopic sleeve gastrectomy
with potential for future improvements as technology continues to advance.

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P494

P496

Portal Vein Thrombosis After Laparoscopic Bariatric Surgery

Its a Rare Complication But Should be Considered: Description
of Three Cases with Literature Review

Short-Term Results of Revision and Conversion Bariatric

Operations

Asem Ghasoup, MD, FACS1, Turki Al Qurashi, MD1, Mohammed

Widinly, MD1, Omar Sadieh, MD, FACS2, 1Security Forces Hospital
Makkah, 2Saad specialty Hospital
Background: Portal Vein Thrombosis (PVT) refers to an obstruction in the trunk of the portal vein its an
uncommon complication after Laparoscopic Bariatric Surgery (LBS) However it is a potentially lifethreatening condition reported after laparoscopic bariatric surgery. Clinical symptoms may be insidious, and
progression can lead to intestinal infarction and portal hypertension.
Main Outcome Measures: Systematic review of the literature on PVT after LBS and report three cases
encountered at our institution.
Patients and Methods: We reviewed the literature between January 1990, and January 2015, using the
search terms portal vein thrombosis, mesenteric venous thrombosis, laparoscopic surgery and bariatric
surgery.
The inclusion criteria were documented PVT by imaging studies such as angiography, ultrasonography,
computed tomography [CT], or magnetic resonance imaging (MRI) or surgery following LBS.
We include three cases after laparoscopic sleeve gastrectomy from our institution.
Results: One developed a chronic cavernoma with extension of the thrombus to the superior mesenteric vein
and splenic vein, the other two cases recovered using anticoagulation therapy.
Conclusions: PVT is a rare complication after LBS, however Laparoscopic surgeons should be aware of the
risk of PVT, and it should be suspected in cases with an atypical outcome after LBS. Once PVT is
diagnosed, prompt anticoagulation therapy may resolve the thrombotic event.

Pornthep Prathanvanich, MD, Eric Marcotte, MD, Bipan Chand, MD,

Loyola University Medical Center
Background: All bariatric operations have an incidence of failure. Revising the gastrojejunostomy (GJ) and
gastric pouch in gastric bypass operations can be performed surgically or endoscopically. Weight regain
after the adjustable gastric band is common converted to either sleeve gastrectomy or gastric bypass. The
aim of this study is to determine the feasibility and outcomes of surgical conversion and revision in failed
bariatric surgery
Method: This is a retrospective study of 34 patients. Patients underwent conversion of gastric banding to
gastric bypass {N = 8} and sleeve gastrectomy {N = 2} as a one stage procedure, and revisions were
offered to 24 patients that had prior gastric bypass. Revisions were of the GJ {N = 14} and endoscopic
suturing {N = 10}
Weight recidivism can be classified into weight regain (gain of 20 % of maximum weight lost){N = 27} or
inadequate weight loss (defined as %EWL \ 50 %) {N = 7}.
All patients underwent preoperative preparation with multi-disciplinary counseling into etiology of failure,
upper endoscopy and contrast imaging.
Result: Between 2012 to 2015, 34 consecutive patients (Female = 29, mean body mass index:
BMI = 45.80 kg/m2, and mean age = 46.21) had a conversion and revision from a primary bariatric
surgery.
Time between primary bariatric surgery and revision or conversion was 9.32 3.07 {Range: 314 years}.
Mean intraoperative blood loss was 29.38 ml with no intraoperative complications. Two (2/34:8.82 %)
major post-op complications occurred early and included one pseudo-Petersons hernia in a patient that
underwent conversion of gastric banding to gastric bypass and one patient with an omental bleed after
laparoscopic revision of the GJ.
Mean follow up time was 10.42 months with mean excess weight loss of 26.73 % and mean total body
weight loss (TBWL) of 18.98 kg. Mean TBWL of surgical conversion of gastric banding to another bariatric
surgery (32.34 kg) was more than of surgical revision of a gastric bypass (13.42 kg) significantly
(p = 0.007).
Conclusion: The conversion from gastric banding to gastric bypass or sleeve gastrectomy can safely be
performed in one stage at an experienced bariatric center and offers significant weight loss. Revising the
anatomy of a gastric bypass is technically feasible and can safely be performed in select patients. However,
weight loss may be modest and timing of the second intervention from index operation may impact
subsequent weight loss.

First visit BMI (kg/m2)

45.80

Excess weight loss (%)

26.73

TBWL (kg)

18.98

P495

P497

The Effect of Laparoscopic Sleeve Gastrectomy on Renal

Function

Restrictive Versus Malabsorptive Bariatric Procedures in Obese

Women of Reproductive Age

Vanessa Falk, MD, Curtis Marcoux, MSc, David Pace, MD, FRCSC,
Felicia Pickard, MD, Priscille Cyr, MD, Smith Chris, MD, FRCSC,
Darrell Boone, MD, FRCSC, Deborah Gregory, MSc, PhD, Laurie
Twells, PhD, Memorial University of Newfoundland

Aaron Purser1, Sallie McSwain1, Angel Farinas, MD2, Christian Cruz,

MD2, Angelina Postoev, MD2, Christopher Ibikunle, MD2, Aliu
Sanni, MD2, 1GRU/UGA Medical Partnership, 2Georgia Surgicare

Introduction: While obesity has been shown to contribute to both the development and progression of renal
failure, the effects of bariatric surgery on post-operative renal function remain poorly understood. We
hypothesize that patients who undergo a laparoscopic sleeve gastrectomy (LSG) have no deterioration of
renal function regardless of their pre-operative renal function.
Methods: This is a retrospective chart review of patients who underwent LSG at a single bariatric center
from May 2011 to February 2014. The primary outcomes assessed were estimated glomerular filtration rate
(eGFR), serum creatinine (Cr) and urea at 6 and 12 months post-operative LSG. Data on patient demographics, pre-operative renal function, weight loss and 30-day postoperative complications were collected.
Patients were further divided into normal pre-operative renal function group (NRF) with eGFR C 60 and
abnormal renal function group (ARF) with eGFR \ 60. Paired Student t-test and independent Student t-tests
were performed to compare pe-operative and post-operative renal function within each group and between
groups, respectively. Chi-Squared test was used for categorical variables. Statistical analysis was performed
using SPSS (Version 21).
Results: Two hundred and nine patients underwent LSG (n = 209). Compared to preoperative renal
function (mean Cr = 71.9 16.2 umol/L), there was no difference in the renal function of patients noted at
6 months (mean Cr = 70.9 18.3 umol/L, p = 0.607) and at 12 months (mean Cr = 72.2 18.1 mmol/
L, p = 0.807). Normal pre-operative eGFR was noted in 192 patients and abnormal renal function was noted
in seventeen patients. Differences in pre-operative renal function between the NRF and ARF groups were
statistically significant (mean Cr = 69.4 12.6umol/L vs. mean Cr = 108.5 29.7umol/L, p \ 0.001 and
mean urea = 5.2 5.4 mmol/L vs. mean urea = 8.1 3.1 mmol/L, p \ 0.001). These groups were
similar with regard to gender distribution ([80 % female), mean pre-operative weight (135 kg), body mass
index (mean 49.2 kg/m2) and obesity related comorbidities. The NRF group was younger (43.2 years vs,
54.0 years, p \ 0.001). The renal function of patients in the NRF group did not change significantly at 6 and
12 months post LSG. While not statistically significant, within the ARF group, there was a general
improvement in post-operative mean eGFR and Cr at 12 months (n = 11; 51.1 8.4 vs. 54.9 7.1 ml/
min/1.73 m2, p = 0.490, 108.5 29.7 vs. 100.1 19.6 umol/L, p = 0.301). Weight loss
(%EBMIL * 59 %kg/m2) and post-operative complications rates were similar in both groups. No mortality
occurred.
Conclusion: LSG does not appear to worsen renal function regardless of pre-operative eGFR.

123

Introduction: In 20112012 in the United States, 36 % of adult women were obese, and the majority of
women in early pregnancy were either overweight or obese. Increasing numbers of young women of
reproductive age seek bariatric surgery each year to achieve sustained weight loss and improve associated
co-morbidities. The objective of this study is to evaluate maternal and fetal outcomes following restrictive or
malabsorptive bariatric surgery.
Methods: A systematic review was conducted through PubMed to identify relevant studies with comparative data on the potential adverse maternal and fetal outcomes when comparing restrictive vs malabsorptive
bariatric procedures in obese women of reproductive age. Specifically, the different adverse outcomes when
undergoing restrictive [laparoscopic sleeve gastrectomy, open vertical and laparoscopic adjustable gastric
banding, silastic ring vertical gastroplasty] versus malabsorptive [gastric bypass (Roux-en-Y), and
bilopancreatic diversion] bariatric procedures were all identified. The primary outcome analysed was fetal
loss. Secondary outcomes included prematurity, NICU admissions, SGA (small for gestational age),
APGAR scores, birth weight, and rate of caesarean delivery. Results are expressed as standard difference in
means with standard error. Statistical analysis was done using fixed-effects meta-analysis to compare the
mean value of the two groups. (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc.,
Englewood, NJ).
Results: Four out of 94 studies were quantitatively assessed and included for meta-analysis, all of which
included retrospective studies at a variety of institutions. Among the four studies, 511 births represented a
past history of restrictive bariatric surgery, whereas 242 births represented a past history of malabsorptive
bariatric surgeries. The incidence of SGA was noted to be significantly higher in patients undergoing
malabsorptive bariatric surgery (-0.527 0.159, p \ 0.001) when compared to the restrictive surgery.
There were no difference in the incidence of fetal loss (0.209 0.036, p \ 0.734), preterm labour
(-0.055 0.103, p \ 0.592), NICU admissions (-0.083 0.179, p \ 0.642), rate of APGAR scores \ 7
at 5 mins (-0.081 0.120, p \ 0.504), birth weight (-0.023 0.113, p \ 0.841) and rate of Caesarean
delivery (-0.001 0.122, p \ 0.996) amongst the two different procedures.
Conclusion: Restrictive or malabsorptive bariatric surgery offers similar outcomes in patients of reproductive age group that desire future pregnancies. Patients undergoing malabsorptive surgery may deliver
babies of small gestational age when compared to the restrictive group.

Surg Endosc (2016) 30:S325S500

S455

P498

P500

An Impact of Bariatric Surgery on Thyroid Function

and Medication Use in Patients with Hypothyroidism.

Laparoscopic Gastric Bypass and Sleeve Gatstrectomy

with an Overnight Stay: Safe and Cost Effective

Alex Zendel, MD1, Yasmin Abu Ghanem, MD1, Tal Yalon, MD1,
Yossi Dux, MD1, Eyal Mor, MD1, Galron Keren, MD2, Dov Zippel1,
Moshe Rubin, MD1, Aviram Nissan, MD1, David Goitein, MD1,
1
General Surgery C, Sheba Medical Center, Israel, 2Pediatric
Emergency Department

Claire McElhatton, Dr1, Elizabeth Vujcich, Dr1, Jeannine McManus,

Dr1, Paul Mousa, Dr2, Matthew J Lyon, Dr1, Kamal Heer, MD3,
Harish Kumar, MD1, 1University of Queensland, 2Prince Charles
hospital, 3Monash Univeristy

Introduction: Bariatric surgery is effective in treating obesity associated co-morbidities. However, the
effect of bariatric surgery on hypothyroid patients is less clear. On one hand, weight loss causes a change in
thyroid hormone levels, particularly TSH reduction. On the other hand, bariatric surgery has an influence on
drugs absorption, due to malabsorptive mechanism and by changing drug pharmacokinetics. The aim of our
study is to assess the effect of bariatric surgery on thyroid function and on thyroid hormone therapy dosage
in patients with hypothyroidism.
Methods: A retrospective analysis of all hypothyroid patients, who underwent bariatric surgery in our
institution, between 20102014, was performed. The patients were evaluated for changes in thyroid hormone levels and in thyroid hormone replacement therapy dosage up to a year from surgery.
Results: Study included 86 patients; 79 female and 9 male at the average age of 47 12. The types of
operations performed were laparoscopic sleeve gastrectomy in 71 (82.6 %) and laparoscopic gastric bypass
in 15 of patients. Patients BMI was significantly reduced from 43.9 6.5 before surgery to 34.6 5.7
(P \ 0.001) and 29.8 5.7 (P \ 0.001), after 6 months and 1 year, respectively. TSH levels decreased
significantly after 6 months from 4.1 2.8 to 2.98 2.7 (P \ 0.05). TSH decrease after 1 year was not
statistically significant. TSH decrease did not correlated with the degree of BMI reduction. At 1 year time
point, patients required lower average dose of thyroid replacement therapy (P \ 0.02). Moreover, in 8
(9.3 %) patients this therapy was completely stopped during 1 year of follow-up.
Conclusion: Our study showed the favorable net effect of bariatric surgery on hypothyroid bariatric population, including improvement of thyroid function and reduction of thyroid medication dosages. Further
studies are required to evaluate an influence of thyroid replacement therapy absorption and to compare
different types of bariatric operations.

P499

Introduction: Since the advent of the Laparoscopic approach mortality and morbidity have decreased in
bariatric surgery. There are conflicting studies for and against the shorter stay. Most of the studies are a
compilation of data from various sources.
The present study prospectively worked with intention to treat. All consecutives patients scheduled to have
primary laparoscopic Roux-En Y gastric bypass (LGBP) or sleeve gastrectomy (LSG) under care of single
bariatric surgeon were recruited. All were expected to be discharged after an overnight stay. This was with
the background of preceding length of stay of 1.8 days [13] over four years.
Method: This abstract is based on preliminary analyzed data of 136 patients. There was no selection bias
and all patients destined to have primary procedure were recruited sequentially.
The service intensified the preoperative counseling. Though there was already an established nursing culture
to mobilize these patients within hours of the operation and educate patients that early mobilization was
beneficial. This education and reassurance extended to their immediate family member[s] or friend[s]
The existing standard technique to do bypass was used. Side to side gastro-jejunostomy using appropriate
endoscopic stapling device was standard.
LSG was fashioned with reinforced staple lining.

Intaroperatively integrity was checked with Methylene-Blue and air-leak tests. Postoperatively all patients had Gastrograffin swallow/meal to check integrity before they were
allowed to have fluids. All patients had access to a telephone number manned by a nurse
who would be available 24/7 for advice.
Results: The interim results reflect outcomes on initial 136 patients [61 % females, 39 % males; 32 LSG
and 104 LGBP]. Age ranged from 23 years to 71 years. Co-morbidities included usual maladies seen in this
group of patients.
Average Weight/BMI: 166 kg and 58.8 kg/m2.
Operative time: 3075 minutes for LSG and 45190 minutes for LGBP.

Outcomes

131/136 [96.3 %]

Laparoscopic Sleeve Gastrectomy with Staple LINE

Concealment: A Case Series and Analysis Of Outcomes
Janine S Hsu, Samaad Malik, MD, MSc, FRCSC, University
of British Columbia
Introduction: Complications with laparoscopic sleeve gastrectomy (LSG) are rare, but have significant
morbidity and mortality. Studies have compared outcomes of staple line reinforcement techniques including
buttressing or oversewing with running sutures. However, few have presented cases of reinforcing with seromuscular sutures that conceal the staple line. This study analyzes outcomes in patients that receive LSG with
staple line concealment.
Methods: A retrospective study on LSGs performed by a single surgeon from 2011 - 2015 at a tertiary care
centre. Inclusion criteria: [18 years old, BMI [ 35 with comorbidities or BMI [ 40. Exclusion criteria:
prior weight-loss surgery.
Results: One hundred and eighty-three patients were included: 158 female (86.3 %), 25 male (13.6 %)
(Tables 1, 2). Mean preoperative age 46.8 10.9 years; mean preoperative BMI 44.4 5.73 kg/m2
(range = 32.33 kg/ m2 to 65.2 kg/ m2). LSGs were performed using 40Fr or 42Fr bougie, staple line start
distance from pylorus: 6 cm, and staple lines were concealed with imbricated continuous suture. The mean
operative time was 52.1 min 11.4 min.
Conclusions: We report low rates of staple line bleeds and staple line leaks with LSG with staple line
concealment. However, a larger prospective trial would be required to further investigate this.

Overnight stay

5/136 [3.7 %]

Stayed an extra night

3/5

Admin mishap/contrast study delay

1/5

Spouse failed to collect patient

1/5

Exacerbation of asthma

2/136

Required dilatation 35 months post OT

There was no leak, 30 day mortality or readmission. At 12 months average EWL was 62.4 %, higher in
LGBP group than LSG.
Conclusion: The strategy to reduce stay appears to be safe and has no impact on complications and expected
goals.

P501
Bariatric Surgery Outcomes in Type 1 Diabetes: A Systematic
Review

Table 1

Major post- operative complication rates

Complication

Staple line leak

Staple line bleed

Stricture Formation

N (%)

0 (0)

1 (0.55)

0 (0)

Table 2

Excess weight loss %post-surgery

Post-operative follow up:

Total Mean EWL %

Age group \60 years
Age group C60 years
p-value (Age groups)
BMI group \50 kg/m2
BMI group C50 kg/m2
p-value (BMI groups)

1 month
EWL %(SD)

3 months
EWL %(SD)

6 months
EWL %(SD)

1 year
EWL %(SD)

15.63 (10.80)

30.57 (11.86)

43.15 (18.78)

46.51 (19.22)

15.79 (11.52)

30.10 (11.59)

44.70 (18.68)

45.25 (19.66)

14.53 (5.97)

30.16 (13.75)

25.95 (13.81)

54.68 (15.80)

0.74

0.99

0.04

0.37

15.79 (11.26)

30.09 (12.34)

42.47 (44.05)

47.20 (19.21)

13.97 (7.31)

30.26 (6.96)

20.00 (13.04)

42.00 (21.62)

0.68

0.97

0.84

Alexandra Chow1, Noah J Switzer1, Jerry T Dang1, Xinzhe Shi1,

Christopher de Gara1, Daniel Birch1, Richdeep S Gill2, Shahzeer
Karmali1, 1University of Alberta, 2University of Calgary
Introduction: We aimed to examine the literature regarding the efficacy of bariatric surgery for patients
with type 1 diabetes (T1D). Bariatric surgery has been shown to be an effective treatment modality for
obesity and its comorbidities, specifically type 2 diabetes (T2D). Remission of T2D after bariatric surgery
has been attributed to gastrointestinal hormone modulation and improvements in residual beta-cell function.
However, few data is available regarding the impact of bariatric surgery in patients with limited residual
beta-cell function, as in T1D. Early small case reports suggest that bariatric surgery leads to reduction in
insulin requirements, in addition to improvements in body mass index and other comorbidities.
Methods and Procedures: A comprehensive search (limited to English and human) of MEDLINE,
EMBASE, SCOPUS, the Cochrane Library, and Web of Science from 1946 to July 2015 was completed.
Title searching was restricted to the following keywords/terms: bariatric surgery, gastric bypass, gastric
band, sleeve gastrectomy and Type 1 Diabetes Mellitus. Inclusion criteria included human adult subjects
with confirmed T1D who underwent a bariatric surgical procedure with diabetes specific outcomes reported.
Results: Thirteen primary studies (86 patients) were included in the systematic review. Subjects had a mean
age of 37.31 years with a mean BMI of 43.55 kg/m2. Post-operative bariatric surgery BMI at 12 months and
at study endpoint dropped significantly to 29.55 kg/m2 (p \ 0.00001) and 30.63 kg/m2 (p \ 0.00001),
respectively. Weighted mean pre-operative daily insulin requirement was 97 units, which dropped markedly
to 35 units/day (p \ 0.00001) at 12 months and 42 units/day (p \ 0.00001) at study endpoint. Weighted
mean pre-operative HbA1C was 8.46 %, which dropped to 7.95 % (p = 0.01) and 8.129 % (p = 0.03) at
12 months and at study endpoint, respectively.
Conclusions: Bariatric surgery leads to marked weight loss in patients with T1D. Favourable post-operative
metabolic effects lead to improvements in glycemic control and a reduction in exogenous insulin use.

0.62

123

S456

Surg Endosc (2016) 30:S325S500

P502

P504

One-Step Short-Stay Conversion from Gastric Banding to Sleeve

Gastrectomy. Safety and Feasibility

Body Composition Change After Bariatric Surgery

Tomas C Jakob, MD, Patricio Cal, MD, Luciano J Deluca, MD,

Ezequiel Fernandez, MD, CRQO
Introduction: Bariatric surgery is the most effective treatment for morbid obesity.
Laparoscopic adjustable gastric banding (LAGB) has few perioperative complications.
However, many patients require a long term revisional surgery, either for weight regain,
reflux, esophageal dilation, slippage or band erosion. Laparoscopic sleeve gastrectomy
(LSG) has consolidated as a primary bariatric technique and also as a revisional procedure.
The safety of a one step revision is a matter of debate. Also, because of its quick postoperatory recovery is disputed if patients benefit or not of a longer than 24 hours hospitalization when performing it as a revisional technique. Main benefits of early discharge are
minimal loss of productivity, costs reduction and less risk of infections.
Methods and Procedures: The objective of this study was to evaluate the safety and
feasibility of one-step short-stay conversion from LAGB to LSG. We prospectively collected data about hospital stay, readmission rate, early and mid-term term major
complications and re-intervention rate on 39 conversions from LAGB to LSG performed
between march 2010 and august 2015.
Results:, Mean age was 48.7 (3562); mean BMI was 45.7 kg/m2 (26.871.5); 81.9 %
were women. Thirty eight patients were discharged in the first 24 hours. Only 1 (2.6 %)
required a longer admission for digestive intolerance. No reinterventions were required. No
leaks, intra-abdominal hematomas or abdominal collections were observed. There was no
mortality.
Conclusions: Evidence suggests that one-step conversion from LAGB to LSG is a safe and
feasible surgery. Hospital stay for more than 24 hours seems unnecessary in patients with
no persistent vomiting or signs of bleeding or leaks.

P503
Laparoscopic Adjustable Gastric Band Migration Causing Total
Port Erosion: an Neglected Case

Narong Boonyagard, MD, Pondech Vichajarn, Rapheephat

Tanomphetsanga, Jakrapan Wittayapairoch, Krit Kitisin, Suppa-ut
Pungpapong, Chadin Tharavej, Patpong Navicharern, Suthep
Udomsawaengsup, Chulalongkorn Hospital
Background: Bariatric surgery is one of treatment choices for morbid obesity patients
because of its effective weight loss. To improve positive effects on metabolic risks, this
weight loss should be primary from body fat mass (BFM). The aim of this study is to
analyze the body composition for determining FFM, BFM, and basal metabolic rate (BMR)
before and after bariatric surgery
Method: Patients performed bariatric surgery in King Chulalongkorn Memorial Hospital
University between September 2014 and March 2015 were prospectively collected.
Patients weights and body compositions were recorded by using bioelectrical impedance
analysis (BIA). Weight, BFM, FFM, and BMR were measured before and 1, 3 and
6 months after bariatric surgery. The changes in body composition were analyzed
Result: A total of 18 patients were included with at least 6 months follow up, 13 for
LRYGB and 5 for LSG. There were 8 females and 10 males with an average age of
36.33 years old. The average BMI before surgery was 52.02 kg/m2 and 6 months after
surgery was 37.84 kg/m2. The average %EWL was 53.37 %. The average of BFM before
surgery and 6 month after surgery were 76.24 22.86 and 46.16 17.21 kg (P \ .001)
respectively. The average of FFM before surgery and 6 month after surgery were
74.86 19.08 and 63.32 15.00 kg (P \ .001) respectively.
In 6 months after surgery, patient had lost 41.62 of body weight (30.08 kg of BFM and
11.54 kg of FFM). We mainly found a decrease in BFM (39.49 12.58 %) whereas FFM
was slightly reduced (14.76 6.87 %).
The significant decrease in BMR (1933.73 401.03 vs 1772.83 356.71 Kcal P \ .001)
was observed only from before surgery to 1 month after surgery. Thereafter, there was no
significant change in BMR at 3 and 6 months (1765.73 374.78, 1737.23 324.05).
Between these two operations, LRYGB seems to preserve overall FFM comparable to LSG.
Conclusion: The weight loss after bariatric surgery is mainly due to a reduction in BFM
with less impact on the FFM (39.49 % vs 14.76 %). BMR

P505

Baris Yildiz, Ankara Numune Teaching Hospital

Introduction: Laparoscopic adjustable gastric banding (LAGB) still keeps it place among
other obesity surgery techniques as an efficient and easy procedure with comparable percent
excess weigth loss. LAGB requires frequent office visits for adjustment of the band via the
port placed under the skin.
Case: 35 years old female patient presented to our outpatient clinic with complaint of
burning feeling inside stomach. The patient had LAGB 4 years earlier. She lost 60 kg in
four years and her body mass index was 31 at current presentation. Her laboratory work up
showed iron and vitamin D deficiencies. Her physical examination revealed an adjustment
port totally eroded out of skin in left upper quadrant under the breast (Figure available).
Upon further questioning she stated that the port was in that position for over two months.
Her upper endoscopy showed that the band migrated into the stomach with its 70 % of
circumference (Figure available). The band was removed laparoscopically without any
complications. The culture of the fluid inside the band did not grow any bacterial or fungal
species.
Discussion: This case points out that LAGB should be applied to well educated patients
who can comply to strict medical follow-up.

123

Gastric Band Removal in Revisional Bariatric Surgery, One-Step

or Two-Step? A Systematic Review and Meta-analysis
Jerry T Dang1, Noah J Switzer1, Jeremy Wu1, Richdeep Gill2, Jeremie
Thereaux3, Xinzhe Shi1, Christopher de Gara1, Daniel Birch1,
Shahzeer Karmali1, 1University of Alberta, 2University of Calgary,
3
Department of General, Digestive and Metabolic Surgery. La Cavale
Blanche University Hospital, University of Bretagne Occidentale
Introduction: We aimed to systematically review the literature comparing the safety of one-step versus
two-step revisional bariatric surgery from LAGB. Bariatric revisional surgery is becoming increasingly
common. Weight regain, band slippage, and pouch dilatation are common patient presentations to a tertiary
bariatric consultant for revision from a previous laparoscopic adjustable gastric band (LAGB). Normally
converted to either a Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), there is considerable
debate in the literature as to the safety of removing the gastric band and performing revisional surgery
immediately or in a delayed, two-step fashion. While one-step operations circumvent the need for a second
surgery, potential higher anastomotic leak rates make one-step operations less appealing.
Methods and Procedures: A comprehensive search of MEDLINE, EMBASE, SCOPUS, the Cochrane
Library, and Web of Science from 1946 to July 2015 was completed. Title searching was restricted to the
following keywords/terms: gastric band* AND revision*/ fail*/remov*/reoperation*. Included studies
contained [5 adult patients comparing one-step and two-step revisional surgery from gastric banding to
either RYGB or SG.
Results: Eleven primary studies (1370 patients) were included. 1006 patients were converted to RYGB and
364 patients to LSG. The main indications for revision were: failed weight loss (59.5 %), vomiting/dysphagia (22.3 %) and pouch dilatation (14.2 %). BMI change was not significantly different for one-step
compared with two-step in the RYGB group (p = 0.99). Weighted mean leak/fistula rates did not vary
between one-step versus two-step in the RYGB (1.9 % versus 2.3 % respectively, p = 0.36) or SG groups
(5.8 % versus 2.8 %, p = 0.26). Overall weighted mean morbidity was also similar between one-step versus
two-step in the RYGB (8.1 % versus 8.9 % respectively, p = 0.76) or SG groups (9.7 % versus 11.2 %,
p = 0.81). There was no difference in mortality rates between the groups.
Conclusion: Immediate or delayed revisional bariatric surgeries are both safe options for the management of
gastric band complications, with acceptable morbidity rates.

Surg Endosc (2016) 30:S325S500

S457

P506

P508

Effect of RY Gastric Bypass Induced Weight Loss on the Dynamic

Of C-Reactive Protein Levels: A Prospective Analysis with a Long
Term Follow Up

Red Cell Distribution Width: A Novel Biomarker

for the Prediction of One-Year Excess Body-Mass Index Loss
Following Laparoscopic Roux-En-Y Gastric Bypass

Piotr J Gorecki, MD, Kendra M Black, MA, MD, Ankeet Udani, MD,
Krystyna Kabata, PA, Anthony Tortolani, MD, New York Methodist
Hospital

Eric S Wise, MD1, Kyle M Hocking, PhD2, Adam Weltz, MD3, Anna
Uebele, MD3, Jose J Diaz, MD, CNS, FACS, FCCM3, Stephen M
Kavic, MD3, Mark D Kligman, MD3, 1Vanderbilt University Dept
of Surgery; University of Maryland Dept of Surgery, 2Vanderbilt
University Dept of Surgery, 3University of Maryland Dept of Surgery

Introduction: It has been shown that morbid obesity is associated with a chronic inflammatory state and is
associated with increased C-reactive protein (CRP) levels. In this study, we examine the dynamics of serum
CRP levels with long term follow up in patients who underwent laparoscopic Roux-en-Y gastric bypass
(LRYGB).
Methods and Procedures: All patients met the NIH criteria for Bariatric surgery and were operated upon
by a single surgeon (PG) in a single institution between June 2006 and January 2008. Demographic data,
weight, BMI, comorbidities and perioperative data were entered into the database prospectively. The same
clinical pathways and the same technique were utilized for all patients. There were no postoperative
mortalities. Serum CRP levels were obtained during routine pre-operative blood work and every year postoperatively up to 6 years. Yearly post-operative CRP levels were compared to the pre-operative CRP levels
using a paired two sample means t-test.
Results: Fifty-three patients (average age 41.0 12.2 years, average BMI 48.2 7.67) were followed for
6 years post-operatively. Routine pre-operative testing showed that 46 patients (87 %) had elevated CRP
levels preoperatively. Significant reduction of serum CRP levels occurred postoperativelysee Table 1.
Conclusion: Our study demonstrates that CRP levels were significantly reduced at 1, 2, 3 and 4 years postoperatively following LRYGB. This study shows that 100 % of post-op patients had clinically normal CRP
levels at 6 years follow-up indicating that bariatric surgery causes a favorable reduction in CRP, a known
inflammatory marker.

Table 1
Follow-up
Time
Pre-op

.
Number
patients

of

Mean CRP SD
(mg/L)

Mean CRP
change

P-value paired
t-test

%with normal CRP

Average
(kg/m2)

53

11.46 8.24

13 %

48.2

1 yr. postop

36

6.8 6.10

-9.41

0.0234

72 %

30.8

2 yr. postop

33

2.26 2.10

-8.88

0.0325

88 %

30.3

3 yr. postop

28

1.30 1.17

-8.71

0.0408

86 %

30.6

4 yr. postop

28

2.21 4.67

-10.37

0.0094

93 %

31.4

5 yr. postop

16

1.59 2.41

-7.36

0.2401

94 %

32

6 yr. postop

2.13 1.01

-3.42

0.6794

100 %

33

BMI

Introduction: Bariatric surgery is the most effective method for producing sustained weight loss and
improving weight-associated comorbidities in the morbidly obese population. The Roux-en-Y gastric bypass is
among the most common and effective operations available, and is routinely performed laparoscopically. The
red cell distribution width (RDW), a marker of size dispersion of circulating erythrocytes, is an emerging
marker of inflammation usually reported as part of the routinely obtained pre-operative complete blood count.
In this study, we tested our hypothesis that RDW represents a biomarker independently predictive of excess
body-mass index loss (EBMIL) following laparoscopic Roux-en-Y gastric bypass (LRYGB).
Methods: Five hundred and forty-seven included LRYGB patients from a single institution were individually reviewed, noting both pre-operative RDW and percent excess BMI loss at six months and one year
post-LRYGB (%EBMIL180 and %EBMIL365, respectively). Bivariate and multivariate linear regression
analysis was conducted between age, gender, initial body-mass index (BMI0) and RDW and each of the two
endpoints, to assess the independence of RDW as a predictor of post-operative success.
Results: The median RDW was 13.9 (13.314.6) %, and median EBMIL180 and EBMIL365 were 55.4 (45.2 66.7) % and 71.3 (58.987.8) %, respectively. Upon bivariate linear regression analysis, both BMI0 (B = -1.1
[-1.2 to -1.0] %, P \ .001) and RDW (B = -3.4 [-4.6 to -2.2] %, P \ .001) were significantly associated
with %EBMIL180, while male gender (B = -8.9 [-13.2 to -4.6] %, P \ .001), BMI0 (B = -1.4 [-1.5 to
-1.2] %, P \ .001) and RDW (B = -4.6 [-6.2 to -3.0] %, P \ .001) were significantly associated
with %EBMIL365. After controlling for age, gender and BMI0, RDW was independently associated with
EBMIL365 (B = -1.4 [-2.8 to -0.002] %, P = .05), but not EBMIL180 (B = -0.6 [-1.6 to 0.5] %,
P = .30. Upon Kruskal-Wallis analysis, patients with a pre-operative RDW [ 15.0 % had significantly lower
%EBMIL than those in the\13.0 % (***P \ .001) and 13.015.0 % (**P \ .01) strata (Fig. 1).
Conclusions: RDW is independently predictive of EBMIL at one year following LRYGB. This represents a
novel, inexpensive and readily available pre-operative biomarker that may provide clinically useful prognostic information for the patient and bariatric care team.

P507
A Single Institution Study Examining the Safety of Early
Discharge Following Laparoscopic Sleeve Gastrectomy
Dina Podolsky, MD, Melanie Howell, Erin Moran-Atkin, MD, Jenny
Choi, MD, Diego Camacho, MD, Montefiore
Introduction: Laparoscopic sleeve gastrectomy (LSG) has been shown to be a highly effective surgical
procedure for the treatment of obesity. The objective of our study was to examine if early discharge affects
readmission rates at 7, 15, and 30 days following discharge.
Methods: A retrospective review of all patients who underwent LSG between January 2013 and December
2014 was performed. The primary endpoint was readmission at 7, 15, and 30 days following hospital
discharge. Secondary endpoints included comparing demographic, co-morbidity, and pain scale data
between readmitted and not readmitted patients.
Results: A total of 656 cases were reviewed. There were 188 patients (29 %) that were discharged on POD
1 and 349 patients (53 %) that were discharged on POD 2. Of the patients discharged on POD 1, a total of 6
(3 %) were readmitted within 30 days of discharge3 (50 %) within 7 days, 2 (33 %) within 15 days, and
1 (16 %) within 30 days. Of the patients discharged on POD 2, a total of 14 (4 %) were readmitted within
30 days7 (50 %) within 7 days, 2 (14 %) within 15 days, and 5 (36 %) within 30 days. The date of
discharge was not found to be significantly associated with re-admission within 30 days (p = 0.7). None of
the demographic factors, including gender, marital status, race, as well as having three or greater comorbidities or an increased pain scale rating at time of discharge were found to be associated with
readmission.
Conclusion: Discharge on post-operative day 1 following a LSG is not associated with an increased
likelihood of being re-admitted within 30 days of discharge. Further studies are needed to elucidate which
factors are associated with an increased risk of re-admission.

Fig. 1 .

P509
Weight Loss at Three Months Post-Operatively Predicts Weight
Loss Success at One Year For Roux-en-Y Gastric Bypass
And Sleeve Gastrectomy
Wayne Yang, MD, Keith Gersin, MD, Dimitrios Stefanidis, MDPhD,
Timothy Kuwada, MD, Carolinas Medical Center
Background: Previous studies have sought to identify early predictors of poor weight loss response that
would allow interventions to be pursued sooner following bariatric surgery. Our goal was to identify the
earliest interval at which failure to meet a threshold of weight loss would predict inadequate results at
12 months post-operatively for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).
Methods: We performed a retrospective review of consecutive patients who underwent bariatric surgery by
a single surgeon between January 2012 and September 2014. We included patients who had complete
follow-up information at 2 weeks, 3 months, 6 months, and 12 months post-operatively. Weight loss at each
interval was expressed as a percentage of excess body weight lost using day of surgery weight as a baseline.
Failure to lose adequate weight was defined as less than 45 % excess body weight loss at 12 months.
Unpaired t-tests were used to compare 3 month weights between those who ultimately lost more than 45 %
of excess body weight at 12 months and those who did not. Fishers exact test was then used to assess
whether failure to reach a mean 3 month excess body weight loss of 36 % would be predictive of failure.
Results: 356 patients were initially identified, 150 of which had complete follow-up information (RYGB = 62
and SG = 88). A wide range of percent excess weight loss was observed at one year following RYGB (mean
56.2 %, range 22.1 % to 100.0 %) and SG (mean 46.4 %, range -1.3 % to 113.2 %). Mean excess body weight
loss at 3 months was significantly higher in those who ultimately achieved weight loss success at 12 months than in
those who failed in both RYGB (36.6 % vs 23.8 %, p \ 0.0001) and SG (37.1 % vs 25.6 %, p \ 0.0001). Of those
who did not achieve at least 36 % excess body weight loss at 3 months, there were significantly more weight loss
failures at 12 months for both RYGB (43.2 % vs 16.0 %, p = 0.0294) and SG (62.3 % vs 22.2 %, p = 0.0010).
Conclusions: Patients at higher risk for eventual weight loss failure can be identified at three months postoperatively. Thus, supplemental weight loss therapy should be considered at this relatively early junction.
More studies are required to determine whether earlier post-operative interventions in those at risk individuals will be beneficial.

123

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P510

P512

Laparoscopic Roux-en-Y Gastric Bypass: Long Term Results

With At Least 10-Year Follow Up

Radiographic Improvement of Hepatic Steatosis after Roux-en-Y

Gastric Bypass

Piotr J Gorecki, MD1, Obaida Batal, MD1, Krystyna Kabata, PA1,

Christine Najjar, MS2, Anthony Tortolani, MD1, 1New York
Methodist Hospital, 2St. Georges University School of Medicine

Joshua S Winder, MD, Brandon J Dudeck, BS, Jerome R Lyn-Sue,

MD, Randy S Haluck, MD, Ann M Rogers, MD, Penn State Hershey
Medical Center

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) remains the gold standard bariatric procedure. Short-term weight loss and improvement or resolution of type 2 Diabetes Mellitus (DMII) and other
comorbidities are well documented. Little data is available on long-term weight loss and remission of DMII.
Methods: This study reports on weight loss and remission of DMII in a consecutive 251 patients operated
between 2001 and 2014 who underwent primary LRYGB with at least 10 year follow up. All patients were
operated in a single institution by a single surgeon utilizing the same technique. All data was collected and
entered into the database prospectively. All patients signed a preoperative contract emphasizing the need for
lifelong annual follow-ups. At 10 years, patients who did not report for the office visit were contacted by
mail and by phone.
Results: There were no conversions to open surgery and no perioperative mortalities. Average postoperative
length of stay was 3.6 days. Patients mean age was 35.6 years. Females represented 91 % of patients.
Patients ethnicity was diverse and represented African Americans (41 %), Caucasians (34 %), Hispanics
18.9 % and 5.2 % from other backgrounds. There was an average of 6.5 comorbidities per patient with
DMII present in 61 (24.3 %) patients. Mean preoperative weight and BMI were 295Lbs and 48.4 kg/m2,
respectively. Fifty-nine (23 %) patients were available for 10-year follow up analysis and 22 (8.2 %) had an
office follow up. Maximum weight loss occurred at 18 months (mean weight 181.8lbs and mean BMI
29.4 kg/m2). At 10 years mean weight has been reduced to 206.5Lbs and mean BMI to 33.4 kg/m2. The
average weight regain between the first and the10th postoperative year was 16.6Lbs. Among 61 (24.3 %)
patients with preoperative DMII, 16 (28.8 %) were available for a 10-year follow up. Remission of DM
occurred in 13 (81.25 %) patients at one year and remained in remission in eight (50 %) patients at 10 years.
The detailed dynamics of annual weight loss and BMIs will be presented.
Disscussion: This study reveals that LRYGB provides durable an effective long-term weight loss and
remission of DMII at 10 years. More long term follow up studies evaluating weight loss and comorbidities
extending beyond the initial 10 years are needed. Such studies are essential in order to predict late outcomes
of LRYGB, particularly in younger patients with life expectancy exceeding several decades.

Introduction: Due to the increasing rates of obesity in developed countries, nonalcoholic fatty liver disease
(NAFLD) is now the most common form of liver disease and the leading cause of cirrhosis in those regions.
As such it is also a risk factor for hepatocellular carcinoma. Prior studies have shown improvement of liver
histopathology after significant weight loss. However, biochemical studies and sonography have not been
shown to be definitive in showing improvement. Computed tomographic (CT) findings of NAFLD include
low attenuation of liver parenchyma and hepatomegaly. We hypothesized that patients undergoing
laparoscopic Roux-en-Y gastric bypass (RYGB) and experiencing significant weight loss would have
radiographic improvement of their NAFLD.
Methods: A retrospective review was performed of all patients who underwent RYGB at this institution. We
then identified patients who had either a preoperative abdominal CT scan or an early postoperative scan
(prior to significant weight loss) as well as those patients with a CT scan performed at more than 60 days
after surgery for any indication. The radiologists interpretations were reviewed and all descriptions of
steatosis, fatty infiltration, fatty liver, fatty changes, or hypodense liver were documented. Furthermore, any
noncontrast CT scans that met diagnostic criteria for steatosis (liver parenchyma measuring B 40 Hounsfield units averaged at 3 locations) were noted. Later scans were searched for similar criteria as well as
evidence of improvement.
Results: 19 patients were identified as having perioperative radiographic evidence of NAFLD. 89.5 % were
female with an average age of 41.5 years and a median body mass index (BMI) of 46.9 kg/m2. 16 of these
patients (84.2 %) showed radiographic improvement of their NAFLD (Fig. 1). The median time period from
initial CT to postoperative CT was 826 days, and the median BMI at that time point was 30.5 kg/m2. The
three patients who did not experience radiographic improvement still experienced weight loss (average BMI
points lost of 19.3 kg/m2).
Conclusions: Although the functional status of the liver was not examined in this study, the radiographic
improvement of NAFLD in this series in 84 % of patients was significant. Routine liver biopsy during
bariatric surgery is probably not indicated. Obesity clearly plays a role in the pathophysiology of NAFLD,
although this does not fully explain our results of 3 patients with substantial weight loss but ongoing
radiographic evidence of NAFLD.

P511
Trends in Prophylactic Ivc Filter Placement Among Bariatric
Operations
John N Afthinos, MD, Karen E Gibbs, MD, Staten Island University
Hospital
Introduction: The prophylactic use of inferior vena cava (IVC) filters for patients undergoing elective
bariatric surgery has been reported in the literature at variable rates. In 2010 a landmark study demonstrated
no benefit, but rather increased complication rates from the use of prophylactic IVC filters. We sought to
evaluate the use and complication rates of prophylactic IVC filters in this clinical setting through the use of a
large national database.
Methods: The National Inpatient Sample (NIS) Database was queried from 2005 to 2011 for patients
undergoing elective, primary bariatric surgery. Operations included were gastric bypass (LRYGB), gastric
band (LAGB), mini-LRYGB and biliopancreatic diversion-duodenal switch (BPDDS). Patients undergoing
revisional surgery were excluded from this study. The patients were analyzed for comorbid conditions,
incidence of prophylactic IVC filter placement, length of stay (LOS) and post-operative morbidity and
mortality. Annual utilization of prophylactic IVC filter placement was also measured. Multivariate
regression analyses were performed to evaluate for risk factors for placement of IVC filter and for factors
leading to in-hospital post-operative mortality.
Results: We identified 741,794 patients of which 454,599 (61 %) underwent LRYGB; 152,867 (21 %)
underwent LAGB; 64,209 (9 %) underwent mini-LRYGB and 70,119 (9 %) underwent BPDDS. The annual
utilization of IVC filters is shown in Table 1. Risk factors for placement of IVC filter prophylactic included:
mini-LRYGB (OR 1.7, p \ 0.001), CKD (OR 2.3, p \ 0.001), severe liver disease (OR 4.4, p = 0.001),
history of DVT to lower extremity unspecified location (OR 19, p \ 0,001), to the proximal leg (OR 31,
p \ 0.001) and to distal leg (OR 9, p \ 0.001). The presence of a prophylactic IVC filter increased the risk
of post-operative mortality by OR 1.9, p \ 0.001.
Conclusions: Overall, the rate of prophylactic IVC filter use is low. Some of the highest utilization occurred
in 2010 and then decreased significantly. The use of a prophylactic IVC filter increased the risk of postoperative mortality. The data speaks against the use of prophylactic IVC filters in bariatric surgery patients.

Table 1 .

123

Left: Preprocedure hypo-attenuation of liver. Right: Same patient post-procedure, now with higher
attenuating liver parenchyma outlining hypodense hepatic vessels

P513
Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic
Gastric Banding Among Morbidly Obese Adolescents
Aslam Ejaz, MD, Robert Kanard, MD, Pankti Patel, MD, Raquel
Gonzalez-Heredia, MD, PhD, Pablo Quadri, MD, Lisa SanchezJohnsen, PhD, Enrique Elli, MD, FACS, UIC
Background: Laparoscopic adjustable gastric banding (LAGB) has a high incidence of long-term failure
and complications. Conversion to laparoscopic sleeve gastrectomy (LSG) in patients with failed LAGB has
gained popularity in recent years. However, outcomes in the adolescent population have not been previously
studied. The aim of this study was to examine reasons for LABG failure, percent excess weight loss, and
perioperative and post-operative outcomes in adolescent patients undergoing LSG after failed LAGB.
Methods: All patients who underwent LSG following failed LAGB were identified at our institution
between January 2006 and December 2014. Patient demographics, reasons for lap band removal, presurgical comorbidities, perioperative outcomes, post-operative complications, operating time, length of
hospitalization, and percent excess weight loss (%EWL) were recorded.
Results: Fourteen patients (10 females, 4 males) underwent LSG following failed LAGB. Mean patient age
at LAGB was 16.2 1.6 years and mean preoperative LAGB BMI was 52.4 9.9 kg/m2. The most
common causes for LAGB failure were gastric pouch enlargement (n = 13, 92.9 %) and weight regain
(n = 4, 30.8 %). Mean time before removal of the LAGB was 3.9 1.6 years. At the time of LSG, mean
preoperative BMI was 48.9 9.7 kg/m2. Nearly one-half of the patients (n = 6, 42.9 %) patients underwent a two-stage operation. No patients experienced a perioperative 30-day complication. Median length of
hospitalization following LSG was 3 days (IQR: 2, 3) and did not differ between patients undergoing a onestage or two-stage operation (p = 0.30). At a median follow-up of 19.6 months, percent excess weight loss
was 28.4 %.
Conclusions: Results from this initial study suggests that LSG should be considered as an option for morbid
obesity among adolescent patients who experience complications after LAGB and/or failure of LAGB.
Future studies with larger samples of adolescent patients as well as a longer follow-up period post LAGB are
warranted.

Surg Endosc (2016) 30:S325S500

S459

P514

P516

Postoperative Day One Neutrophil-to-Lymphocyte Ratio

as a Predictor of 30-Day Outcomes in Bariatric Surgery Patients

Pancreaticopleural Fistula: As a One of Complication of Bariatric

Surgery

Matthew Da Silva, BMSc1, Ahmad Elnahas, MD, MSc, FRCSC2,

Michelle C Cleghorn, MSc2, Timothy D Jackson, MD, MPH, FRCSC,
FACS2, Allan Okrainec, MDCM, MHPE, FRCSC, FACS2, Fayez
A Quereshy, MD, MBA, FRCSC2, 1University of Toronto, Faculty
of Medicine, 2University Health Network, Division of General
Surgery

Mohammed Al ismail1, Naif Al-Thobaiti2, Yasser Al Jehani, PhD2,

1
King Abdulaziz hospital, National Guard of Al Ahsa, 2King Fahad
hospital of Dammam university

Introduction: The neutrophil-to-lymphocyte ratio (NLR) is a marker that reflects systemic inflammation
and organ dysfunction. Its use as a prognostic marker to predict complications following surgery has been
recently described in the literature. The objective of our study was to evaluate the use of a high postoperative
day one (POD1) NLR as a predictor for 30-day outcomes in patients undergoing bariatric surgery.
Methods and Procedures: We performed a retrospective chart review of 792 patients who underwent
bariatric surgery at our institution between March 2012 and May 2014. Data was collected from medical
charts, the National Surgical Quality Improvement Program and the Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program databases. POD1 NLR values were obtained from complete blood counts along with a variety of 30-day clinical outcomes. Univariate and multivariate analyses
were conducted to determine if POD1 NLR C 10 could predict 30-day outcomes. This threshold was chosen
because of its previously reported predictive value in gastrointestinal surgery.
Results: 699 Roux-en-Y gastric bypass surgeries (88 %), and 93 sleeve gastrectomy surgeries (12 %) were
performed. All surgeries were performed laparoscopically. A total of 86 (10.9 %) complications occurred in
our study population, with 47 (5.9 %) considered to be major. After covariate adjustment, POD1 NLR was
found to be significantly associated with overall complications (OR 1.98, 95 % CI: 1.013.87), major
complications (OR 3.71, 95 % CI: 1.767.82), reoperation (OR 3.63, 95 % CI: 1.1411.6), and a postoperative length of stay greater than 2 days (OR 3.7, 95 % CI: 2.26.22). Although POD1 NLR was associated
with readmission on univariate analysis, significance was not retained on multivariate analysis.
Conclusions: In our review of a large number of patients undergoing bariatric surgery, a POD1 NLR C 10
was able to independently predict 30-day outcomes. This easily obtained inflammatory marker may help
identify patients with a higher risk of developing early complications who may require longer hospital stay
or reoperation. Further studies are needed to validate this threshold and explore its future clinical
implications.

P515
An Intraoperative Technique to Reduce Superficial Surgical Site
Infections in Laparoscopic Roux-en-Y Gastric Bypass
Constructed by Circular Stapler
Yang Zhang1, Oscar K Serrano, MD2, W S Melvin, MD, FACS2,
Diego R Camacho, MD, FACS2, 1Albert Einstein College
of Medicine, 2Montefiore Medical Center
Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LGBP) has been established as one of the most
effective treatments for morbid obesity. Surgical site infections (SSI) are the most common complication
following LGBP, affecting as many as 12 % of patients.
Methods: We developed an intraoperative technique to reduce superficial SSI (sSSI) during LGBP constructed by circular EEA stapler. Our technique relies on sterile plastic coverage of the EEA stapler, sterile
specimen-bag retrieval of the gastrojejunostomy enteric remnant, and Penrose drainage of the port used to
introduce the EEA stapler for 24 hours post-operatively. Using the Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program registry, we analyzed our sSSI outcomes before and after
implementation of our technique during LGBP performed by a single surgeon between January 2009 and
February 2015. We compared the sSSI rate between the two groups taking into consideration patient age,
sex, baseline BMI, smoking status, and comorbidities such as diabetes, hypertension, and hyperlipidemia.
Chi-Square and multivariate analysis were performed.
Results: Between January 2009 and February 2015, we performed 486 LGBP. The cohort before implementation of our technique (Group #1) included 164 patients (33.7 %) and the cohort after implementation
(Group #2) included 322 patients (66.3 %). Both groups were similar in terms of age, sex, smoking status,
and rates of diabetes and hyperlipidemia, but differed in BMI (48.3 kg/m2 in #1; 46.1 kg/m2 in #2),
operative time (2.44 hours in #1; 1.87 hours in #2) and prevalence of hypertension (37.8 % in #1; 48.8 % in
#2). Hypertension was not a confounder for sSSI (p = 0.35). The sSSI rate was 9.15 % for Group #1, and
3.42 % for Group #2 (p = 0.0079). Controlling for BMI and operative time, multivariate analysis revealed a
significant reduction in sSSI (odds ratio 2.98 [95 % CI 1.336.69]) with our technique.
Conclusion: We describe a reproducible intraoperative technique that significantly reduces sSSI in EEAconstructed LGBP procedures. Our technique has the potential of hastening postoperative recovery and
lowering perioperative costs.

Pleuropulmonary complications of pancreatitis are rare. Pancreaticopleuralfistula (PPF) could be a consequence of pancreatitis in post-bariatric patients. Pancreatic stenting by using endoscopic retrograde
cholangiopancreatography (ERCP) is difficult in abnormal upper gastrointestinal anatomy, and percutaneous
route is difficult in mesh repair of incisional abdominal hernia. We represent a case of a 35-year-old female
with biliopancreatic diversion admitted with recurrent episode of pancreatitis, complicated with pseudocyst
and development of a pancreaticopleural fistula. Successful medical management was achieved, and she
made a full recovery. This case demonstrates that the rarity of such a condition leads to delay as well as
challenges in diagnosis and management.

P517
Comparison of Diabetic Remission Rates Following Roux en-Y
Gastric Bypass and Longitudinal Sleeve Gastrectomy
Zachary Weitzner, Richard Perugini, MD, John Kelly, MD, Donald
Czerniach, MD, Philip Cohen, MD, Julie Flahive, Gordon Fitzgerald,
University of Massachusetts Medical School
Introduction: Bariatric surgery is being increasingly investigated as treatment for Type II Diabetes Mellitus
(T2DM). As Sleeve Gastrectomy (SG) surpasses Roux-en-Y Gastric Bypass (RYGB) as the new standard in
bariatric surgery, it is still unknown if its efficacy in achieving remission is comparable to RYGB. This study
compared diabetic remission rates between SG and RYGB in order to identify the predictive factors for
remission and the mechanisms of achieving remission.
Methods: This was a retrospective cohort study comparing all diabetic patients undergoing RYGB and SG
at an academic medical center from 1/1/117/1/15. Patients were followed preoperatively and at 6 week,
6 month, and 1, 2, and 3 year intervals. We defined diabetic remission as HbA1c under 7 without insulin or
hypoglycemic use and excess body weight (EBW) as percent over ideal body weight. Data were analyzed
using Cox analysis, Fishers Exact Tests, and Student T Tests.
Results: During the study, 96 patients underwent RYGB and 89 underwent SG. Preoperatively, patients
from both groups had similar age, weight, gender, preoperative weight loss, HbA1c at onset and at surgery,
oral hypoglycemic use, insulin use, and HOMA2 parameters. At one year postoperatively, patients who
underwent RYGB showed a statistically greater postoperative EBW loss (62 % vs. 36 % p \ 0.0001).
Kaplan Meier analysis showed a significantly higher rate of remission, (83 % vs. 66 %) in patients who
underwent SG (p = 0.02). After using Cox analysis to account for differences in delta BMI (p = 0.04),
EBW loss (p = 0.04), preoperative HOMA2 parameters (p = 0.0080.011), and preoperative factors such
as HbA1c and insulin use (p = 0.001 for both), there was no change in RYGBs impact on diabetic
remission compared to SG.
Conclusion: Our results confirm that RYGB achieves a significantly greater rate of diabetic remission and a
significantly higher weight loss than SG. Additionally, the difference in rate of diabetic remission is not
explained by weight loss or preoperative predictors of less reversible diabetes (HOMA2 parameters, use of
insulin). Identification of the factor(s) responsible for this differential effect on diabetes may afford
opportunity for therapeutic intervention.

123

S460

Surg Endosc (2016) 30:S325S500

P518

P519

Prospective Study Comparing Roux-en-Y Gastric Bypass

and Sleeve Gastrectomy on the Resolution of Obesity
and Diabetes in a Native Hawaiian Population

True Incidence of Gastrointestinal Stromal Tumors: Is it Hight

than We Anticipated?

Eden S Koo1, Racquel S Bueno, MD, FACS2, Cedric S Lorenzo,

MD2, 1University of Michigan, 2University of Hawaii Department
of Surgery
Introduction: Obesity and diabetes disproportionately affect Native Hawaiians (NH). Bariatric surgery, specifically the Roux-en-Y gastric bypass (RYGB),
has been proven to be an effective treatment for both obesity and type 2 diabetes mellitus (T2DM) in this population. In recent years, the sleeve gastrectomy
(SG) has become more popular than the RYGB due in part to a belief in its equivalent effectiveness as a treatment for both obesity and T2DM. Because of
the paucity of long-term data supporting this, we sought to prospectively study and compare the effects of the LRYGB and SG on weight loss and diabetes
resolution in a population of obese, diabetic Native Hawaiians.
Methods and Procedures: Twenty-five morbidly obese, diabetic Native Hawaiian patients were prospectively randomized into two groups. Fifteen
underwent RYGB while 10 underwent SG. Clinical data was collected extending as far as 24 months post-operation. Patient weight loss trends and other
diagnostic data include fasting blood sugar (FBS) and hemoglobin A1C (HbA1c) were collected. Data was analyzed for statistical significance.
Results: Both groups were equally matched in regards to gender, age, preoperative weight, BMI, FBS levels and HbA1C. Mean %EBW loss, %FBS
and %HbA1C decrease postoperatively are presented in the following graphs and tables. There was no statistically significant difference between the two
groups.

Conclusion: Our data demonstrates minimal difference over time between SG and RYGB groups on most outcome measures, suggesting that the two groups
are comparable in terms of postoperative weight loss and improvement in T2DM. Both bariatric surgical procedures are therefore viable options in patients
seeking to treat both their obesity and diabetes.

123

Shoshana Hacker, MD, Hernan Urrego, MD, Karleena Tuggle,

Atlanta Medical Center
Introduction: Gastrointestinal tumors are rare tumors of the gastrointestinal tract. These tumors are found within the submucosal layers of the bowel
therefore making their diagnosis difficult on Esophagogastroduodenoscopy. Gastrointestinal stromal tumors are most commonly found in the stomach. There
incidence is 1 per 100,000 in the general population. Morbidly obese patients undergoing sleeve gastrectomy provide access to additional pathology from the
excised stomach specimen taken in their procedure that could not otherwise be evaluated in asymptomatic patients.
Hypothesis: The incidence of gastrointestinal stromal tumor in the general population may be higher than originally described. A number of patients with
asymptomatic gastrointestinal stromal tumors can be identified on gastric sleeve pathology.
Methods: A retrospective analysis of 275 patients who underwent laparoscopic sleeve gastrectomy between the dates August 2014 to August 2015 at a
bariatric center of excellence was conducted. Pathology of all specimens was reviewed. Patient demographics were collected such as age, gender, comorbidities and tobacco history. The prevalence of gastrointestinal stromal tumors in the gastric sleeve population was compared to the prevalence of
gastrointestinal stromal tumors in the general population.
Results: Pathologic findings were evaluated in the patients that underwent laparoscopic gastric sleeve procedure between of the dates of August 2014 to
August 2015. 275 reports were reviewed. Three patients were found to have gastrointestinal stromal tumors in the resected gastric specimen. The incidence
of gastrointestinal stromal tumors in the laparoscopic gastric sleeve population was 1.1 %. The size of the gastrointestinal stromal tumors ranged between
0.51 cm. Patients that were found to have gastrointestinal stromal tumors had a common finding of size less than 0.5 cm and low mitotic rate. None of the
patient required further treatment for their tumors.
Conclusion: The incidence of asymptomatic gastrointestinal tumors seen in gastric sleeve patients was higher than those estimated in the general
population, 1.1 % vs. 0.001 % respectively which was statistically significant. (T score 1.815, P value of 0.03509.) There may be a correlation between
gastrointestinal tumors in obesity that reveals a higher incidence in this selection of patients.

Surg Endosc (2016) 30:S325S500

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P521

P523

Diabetes Remission Following Gastric Bypass: Does Diarem

Stand the Test of Time?

Obalon Gastric Balloon: Kuwait Experience

J. Hunter Mehaffey, MD, Matthew G Mullen, MD,

Rachel L Mehaffey, MD, Florence E Turrentine, PhD, RN,
Steven K Malin, PhD, Bruce Schirmer, MD, Peter T Hallowell, MD,
University of Virginia
Objective(s): Amelioration of type 2 diabetes mellitus (T2DM) is well-known to occur after Roux-en-Y Gastric Bypass (RYGB). Although the
DiaREM score is a novel method for predicting T2DM resolution up to 1-year post-RYGB, no data exist for long-term validity. Therefore, we sought
to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years respectively following RYGB.
Methods: T2DM patients (Age: 48, BMI: 46, HbA1C: 8.1) undergoing RYGB at the University of Virginia between 20042006 (n = 42) and
20122014 (n = 59) were evaluated prospectively to assess pre-operative DiaREM score, defined from insulin use, age, HbA1c and type of
antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines. Chi square test was used to
compare patients T2DM status to their DiaREM probability of remission.
Results: Among RYGB patients with 2-year post-operative data, 2 were lost (n = 1 no follow-up and n = 1 died) resulting in 57 patients for
analysis. For the 10-year postoperative data, 11 were lost (n = 6 no follow up and n = 5 died) thereby resulting in only 31 patients for analysis.
Table 1 displays patients stratified by preoperative DiaREM scores, with the probability of T2DM remission as well as the actual percent remission
at 2- and 10-years. There was no statistical difference in the DiaREM predicted compared with actual T2DM remission rate at either time-point (all
p [ 0.05).
Conclusions: Pre-operative DiaREM scores are a good tool for predicting both short- and long-term T2DM remission following RYGB. This study
represents the first evaluation of this model in T2DM patients up to 10 years after bariatric surgery.

2-Year
pvalue

10-year
Remission (%)

Background: The era of bariatric surgery has been dynamically evolving from the 1950s till day. Considering the possible complications that
patients may face postoperatively, less invasive options were brought into the horizon. One of these options is the obalon gastric balloon, in which
patients swallow the obalon gastric balloon capsule and then it is filled with 250 cc of volume. It is designed to trigger satiety by partially filling the
stomach and therefore, over 12 weeks period, induce weight loss.
Objectives: To assess the benefit of obalon gastric balloon for those who seek noninvasive solutions for weight loss.
Methods: A prospective study of 72 patients who presented to our clinic seeking endoscopic management for obesity. Most of the patients were
already aware of the obalon gastric balloon. Data was collected in a period of 10 months; November 2014 till September 2015. Consent was taken
from our patients that they will be involved in the study.
Results: Patients were studied over a period of 10 months. The median age of patients was 33 (1359) and 75 % were females. Patients BMI was
categorized into overweight (2529.9 kg/m2), class I obesity (3034.9 kg/m2), class II obesity (3539.9 kg/m2), and class III obesity (C 40 kg/m2).
The obalon gastric balloon has been administered and patients were followed up for an average period of 12 months. patients weight was taken after
that period and the percentage of excess weight loss median was 19.4 % (-6.4 %47.2 %). Percentage of excess weight loss peaked among class I
obesity patients (p = 0.003).
Conclusion: The obalon gastric balloon can be an option for those who seek weight reduction solutions. Weight loss was observed among all classes
of obesity, but peaked among those in class I obesity. Although the study was limited by the small sample size (72 patients), and the fact that some of
them failed to show for follow-up, we strongly believe that the obalon gastric balloon has a very big potential in a country where 64.2 % of its adults
are overweight. The study will continue until a much bigger sample size can be obtained.

P524

Pre-operative DiaREM Score Validation of T2DM Remission at 2- and 10-years

Table 1

Yousef Almuhanna1, Fahad Alasfar, Prof2, Fatemah Alotaibi2,

1
KIMS, 2Kuwait University

10Year
p-value

DiaREM
score

Avg probability
of remission (%)

2-Year
remission (%)

02

94

100

0.61

100

0.72

37

76

94

0.08

83

0.57

812

36

47

0.38

43

0.72

1317

22

20

0.92

33

0.64

1822

15

0.40

14

0.64

P522
Safety and Efficacy of Gastric Bypass Versus Sleeve Gastrectomy
in Patients 65 and Older
Lisandro Montorfano, MD, Federico Perez Quirante, MD, Alex
Ordonez, MD, Nisha Dhanabalsamy, MD, Rammohan Rajmohan,
MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel
Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS,
FASMBS, Cleveland Clinic Florida

The Use of Predictive Markers for the Development of A Model

to Predict Lowest Quartile Weight Loss Following Vertical Sleeve
Gastrectomy
Samuel Cottam1, Daniel Cottam, MD1, Mitchell Roslin2, Hinali
Zaveri, MD1, Amit K Surve, MD1, Christina Richards1, Walter
Medlin1, Austin Cottam1, 1Bariatric Medicine Institute, 2Lenox Hill
Hospital
Introduction: Although average percent excess weight loss data is commonly discussed preoperatively to guide patient expectations, there is a wide
range and variation following Vertical Sleeve Gastrectomy (VSG). Unfortunately, there are relatively few predictors that allow for individual
guidance of weight loss. This analysis purpose is to compare patients percent weight loss and determine if any statistically significant variables are
predictive of weight loss and develop a model that predicts weight loss underperformance.
Method: 124 Patients who underwent the SG had data points that were adequate for analysis. These patients underwent surgery between October
2008 and April 2014. Data was gathered. Non-linear regression was performed in order to interpolate patient weights at one year. Multivariate
analysis was used to find factors that effected weight loss. Then using that data a model was constructed to predict weight loss performance in any
practice.
Results: Patients were divided in %EWL quartiles. Multiple logistic regression was used to find that Diabetes and Preoperative BMI were
influencing factors in %EWL at one year. Using this data our model had Positive and Negative predictor values of 86 % and 87 % respectively.
Conclusion: Patients with a BMI greater than 54 or patients with Type 2 Diabetes Mellitus (DM) and a BMI greater than 43 are more likely to be in
the bottom quarter. This information should be discussed and consideration given to performing a more aggressive procedure when a patients
objective is to have a BMI below the obesity threshold of 30.

Introduction: The aim of our study was to compare the safety and efficacy of Laparoscopic Rouxen-Y gastric bypass (LRYGB) and Sleeve
Gastrectomy (LSG) in patients aged C 65 years.
Material and Methods: A retrospective review of a prospectively collected database was performed. All the patients with ages C 65who underwent
LRYGB or LSG between 2010 and 2014 were analyzed. Demographics, preoperative body mass index (BMI), postoperative complications,
postoperative BMI and readmissions were recorded and compared between procedures.
Results: A total of 115 patients were identified. Of these patients, seventy five (65.2 %) underwent LSG and forty (34.7 %) underwent LRYGB. The
mean age of the LSG group was 68 years old (range 6672) and the mean age of the LRYGB group was 67 years old (range 6669) (p = 0.025) In
the LSG group 38 were women (51 %) and 37 were men (49 %). In the LRYGB group 25 were women (62 %) and 15 were men (38 %). The mean
preoperative weight and body mass index (BMI) was 116 kg (range 104127 Kg) and 40 kg/m2 (range 3845) for the LSG group and 119 kg (range
103130 Kg.) and 41 kg/m2 (range 3746) for the LRYGB group. When comparing both groups we did not find a significant difference regarding
preoperative weight (p = 0.71) and preoperative BMI (p = 0.76).
The overall incidence of postoperative complications was 32.5 % (13 patients) for the RYGB group and 9.3 % (7 patients) for the LSG group. The
incidence of postoperative new marginal ulcers (p \ 0.001) and de novo regurgitation (p = 0.031) was higher for the LRYGB group (Table 1).
Regarding readmissions, 4 patients (10 %) that underwent LRYGB and 7 patients (9 %) that underwent LSG were readmitted at least one time.
(p = 0.91)
The trend of postoperative BMI loss was similar for both procedures and no significant difference was found. (Table 2)
Conclusion: According to our data both procedures have a similar efficacy and the same rate of readmissions. On the other hand, our study showed
that LRYGB has more complications than LSG in the elderly. We conclude that Sleeve Gastrectomy might be a safer choice in patients C 65 years.

Table 1

Complications among procedures

Table 2

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P525

P527

The Impact of Enhanced Recovery Protocol for Patients

Undergoing Bariatric Laparoscopic Sleeve Gastrectomy

Medium-Term Results of Laparoscopic Gastric Plication

for the Treatment of Obesity

Katelyn Mellion, MD, Katie Meister, MD, Anna Uebele, MD, Lala
Hussain, Kevin Tymitz, MD, George Kerlakian, MD, Good Samaritan
Hospital

Matthew J Davis, MD, Michael Mulcahy, MD, Deanne Nash, RN,

Matthew Kroh, MD, Philip Schauer, MD, Ali Aminian, MD, Stacy
Brethauer, MD, Cleveland Clinic

Introduction: Enhanced recovery protocols (ERP) standardize perioperative patient care in an

effort to hasten recovery by minimizing the stress response of surgery, improving pain control, and
accelerating gastrointestinal function. The purpose of this study is to evaluate the outcome of
implementing an ERP for bariatric patients undergoing laparoscopic sleeve gastrectomy (LSG).
Methods and Procedures: The bariatric ERP was created to address the specific needs of morbidly
obese patients undergoing foregut surgery. Specific modalities include: extensive preoperative
patient education, regimented oral hydration until 3 hours preoperatively, multimodal pain management (pregabalin and celecoxib preoperatively, narcotic and non-narcotic analgesia
postoperatively), judicious use of perioperative intravenous fluids, and early Foley catheter
removal, ambulation, and enteral feeding. This retrospective study examines outcomes of bariatric
LSG specific ERP from January 2013 to June 2015. Exclusion criteria include patients who
underwent LSG for reasons other than weight loss, whose procedure was abandoned, or who
concomitantly underwent another procedure. Demographic data include: age, gender, preoperative
body mass index (BMI), preoperative comorbidities, American Society of Anesthesiologists (ASA)
class. Outcome variables include: length of stay (LOS), 30-day readmission, 30-day reoperation,
30-day ICU admission. Mann Whitney U and Fishers Exact tests were used to determine the effect
of preoperative comorbidities on patient LOS and 30-day readmission, respectively. 30-day
readmission rate was compared between patients before and after ERP implementation with Chisquare test. P \ 0.05 was deemed statistically significant.
Results: A total of 88 patients were analyzed. Average age and preoperative BMI were 45.7 (10.9)
years and 44.6 (9.8) kg/m2, respectively. The cohort was 15.9 % male. Preoperative comorbidities
included: diabetes (15.9 %), hypertension (33.0 %), history of pulmonary embolism (1.1 %),
cardiovascular disease (0 %), chronic obstructive pulmonary disease (2.3 %), gastroesophageal
reflux (22.7 %), tobacco use (9.1 %), severe limitation to ambulation (3.4 %). The ASA classes of
patients undergoing LSG were II (21.6 %), III (77.3 %), and IV (1.1 %). Average LOS, 30-day
readmission, 30-day reoperation, and 30-day ICU admission were 2.09 days, 8.0 %, 0 %, and 0 %,
respectively. Patients with hypertension were more likely to be readmitted within 30 days
(p = 0.037). 30-day readmission rate prior to ERP implementation was 16.2 % vs 8 % after
(p = 0.111).
Conclusion: We have reported outcomes of using an ERP specific to bariatric patients undergoing
LSG. There is a trend toward fewer readmissions in ERP patients compared to patients undergoing
LSG without an ERP. Patients with hypertension are more likely to be readmitted. Future studies
are needed to further compare outcomes between non-ERP and ERP populations.

Background: Currently, sleeve gastrectomy (SG) is the most common bariatric surgery performed
in the U.S., followed by Roux-en-Y gastric bypass (RYGB) and, to an increasingly smaller extent,
adjustable gastric banding (AGB). However, not all patients are willing to undergo one of these
procedures. Several years ago, gastric volume reduction via greater curvature plication was
described by our group and was demonstrated to be both safe and with moderate efficacy in the
short-term. The aim of this study is to report our medium-term experience with laparoscopic gastric
volume reduction via plication.
Methods: All procedures were performed under an IRB approved protocol at a single academic
center. 42 patients who were at least 1 year removed from laparoscopic gastric plication (LGP)
were identified. Surgeries were performed between November 2008 and October 2012. Demographic characteristics, pre- and post-operative data, and outcomes were collected and analyzed.
Results: Mean age for the cohort was 41 11 years. 81 % of patients were female. Mean preoperative BMI was 43 4 kg/m2 (range, 3353). Mean operative time and estimated blood loss
was 117 35 minutes and 29 50 cc, respectively.
At a mean follow-up of 42 20 months (range, 1276), patients had an average BMI decrease of
7.1 4.8 kg/m2. Percent excess body weight loss (%EWL) was 28 21 %. Percent total body
weight loss (%TWL) was 14 10 %.
Post-operatively, there were 4 complications (9.5 %). This included 1 leak, 2 gastric obstructions
and 1 intra-abdominal abscess. 2 of these patients underwent reoperation in the early post-operative
period. Of the total cohort, two patients subsequently underwent conversion for failed weight loss,
one to SG and one to RYGB. There were no 30-day post-operative mortalities.
Conclusions: Gastric plication may be a reasonable alternative for some patients who are not
interested in more standard procedures, but medium-term weight loss is generally insufficient for
higher BMI patients.

P526
Evaluating the Effect of Technique and Devices on Leaks After
Laparoscopic Sleeve Gastrectomy
Oliver A Varban, MD1, Ruth B Cassidy, MA2, Kyle H Sheetz, MD1,
Amanda Stricklen, MS, RN2, Carl Pesta, DO3, Jeffery Genaw, MD3,
Arthur M Carlin, MD3, Jonathan F Finks, MD1, 1University
of Michigan Health System, 2Center for Healthcare Outcomes
and Policy, University of Michigan, MI, 3Henry Ford Health System
Objective: To assess the effect of technique and surgical devices on staple line leaks after
laparoscopic sleeve gastrectomy (LSG).
Background: Staple line leaks after LSG are a major source of morbidity and mortality. Variations
in technique and devices used to perform LSG exists, however their effect on leaks is poorly
understood.
Methods: We performed a case-control study comparing patients who sustained a leak after
undergoing a primary LSG to those that did not. A total of 45 (0.40 %) patients with leaks were
identified between January 2007 and December 2013. The leak group was matched 1:2 to a control
group based on procedure type, age, body mass index (BMI), sex and year the procedure was
performed. Technique and device specific factors were assessed by reviewing operative notes from
all primary bariatric procedures in our study population.
Results: Leak rates after LSG have decreased over the past 5 years (0.93 % to 0.20 %) despite
variations in technique and device use. The only technique specific factor associated with a lower
rate of leaks was oversewing of the staple line (OR 0.218, CI 0.0710.672, p = 0.008). Surgeons
who oversewed routinely were also found to have higher case volume (307 vs 140, p = 0.0216)
and less overall complication rate (4.81 % vs 7.95 %, p = 0.0027). Stapler vendor was associated
with a higher rate of leaks on univariate analysis but not after controlling for confounding factors.
Use of buttressing material, fibrin sealant and drains did not affect leak rates significantly.
Conclusions: Despite variations in technique, leak rates have decreased over the past 5 years.
Oversewing of the staple line was associated with less leaks after LSG and was performed routinely
by more experienced surgeons with less overall complication rates. Vendor, buttressing material,
drains and fibrin sealant had no apparent effect. Surgeons should reconsider the use of superfluous
and costly devices as a means of reducing leaks after LSG until further evidence justifies their use.

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P528
Is Laparoscopic Splenectomy Safe in Patients with Immune
Thrombocytopenic Purpura and Very Low Platelet Count:
A Single-Institution Experience
Nihat Aksakal, MD, Umut Barbaros, MD, Orhan Agcaoglu, MD,
Mustafa Tukenmez, MD, Berkay Kilic, MD, Omer Cucuk, MD,
Ridvan Seven, MD, Ahmet Dinccag, MD, Selcuk Mercan, MD,
Istanbul School of Medicine
Purpose: Minimal invasive procedures has become increasingly popular during the last decades.
The aim of thisretrospective study was to evaluate the safety and feasibility of laparoscopic
splenectomy in patients with immune thrombocytopenic purpura who has very low platelet counts.
Methods: Between March 28, 2005 and June 08, 2013, a total of 132 patients with the diagnosis of
immune thrombocytopenic purpura were included to study. The patients who underwent laparoscopic splenectomy were alienated into two groups according to their platelet counts lower than
10000 (group 1) and higher than 10000 (group 2)
Results: There were 16 patients in group 1 with very low platelet counts, and 116 in group 2. One
patient in group 1 had converted to laparotomy due to peroperative bleeding, and there were 5
conversion to open in group 2. There were also 2 patients in group 2 who underwent laparatomy on
post operative day 1 due to delayed intra-abdominal bleeding. Moreover, one patient in each group
had pancreatic fistula.
Conclusions: Laparoscopic splenectomy is a safe technique in patients with ITP even the patients
have very low platelet counts.

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P529

P531

Laparoscopic Revision of Percutaneously Placed Malfunctioning

Peritoneal Dialysis Catheters in Eight Patients with Kidney
Failure

New Technique for One Gland Parathyroidectomy by Endoscopic

and Robotic Bilateral Axillo-Breast Approach (BABA): A Case
Series Study

Baris D Yildiz, MD, ANKARA NUMUNE TEACHING HOSPITAL

Hyeong Won Yu, MD4, Jin Wook Yi, MD4, Ra-Yeong Song4, JoonHyop Lee3, Seong Ho Yoo, MD1, Su-jin Kim, MD, PhD4, Young Jun
Chai, MD2, June Young Choi, MD3, Kyu Eun Lee, MD, PhD4,
4
Department of Surgery, Seoul National University Hospital
and College of Medicine, Seoul, Repubic of Korea, 3Department
of Surgery, Seoul National University Bundang Hospital, Seongnamsi, Gyeonggi-do, Republic of Korea, 1Biomedical Research Institute
and Institute of Forensic Medicine, Seoul National University
Hospital & College of Medicine, Seoul, Republic of Korea,
2
Department of Surgery, Seoul National University Boramae
Hospital, Seoul, Republic of Korea

Introduction: Peritoneal dialysis catheter is usually the firstline treatment for patients who have
kidney failure. The procedure is usually carried out by nephrologists under local anesthesia and the
catheter is placed blindly into the abdomen.
Methods and Patients: Eight patients who had peritoneal dialysis catheter placement where
referred for catheter dysfunction. Catheter dysfunction was first detected by the dialysis nurse and
verified by the nephrologist. Then typical conservative interventions (i.e irrigation, laxatives etc)
were undertaken for every patient. Every patient had an abdominal X-ray to verify the position of
the catheter inside abdomen. All patients had laparoscopic revision of the catheters under general
anesthesia. One ten milimeter port was inserted supra umbilically, one ten milimeter trocar was
placed in right upper quadrant and one 5 millimeter trocar was placed in left lower quadrant. After
freeing the catheter the tip of the catheter was taken out via the right upper quadrant trocar and
thoroughly cleaned with removal of the tissue trapped within the holes of the catheter. The catheter
was returned to abdomen and stitched to the peritoneum in right lower abdominal wall. Low flow
irrigation was started immediately after surgery.
Results: The mean time of referral since initial catheter placement was 6.4 days. Mean surgery
length was 37 minutes. All patients had infra umblical midline incision and a left lateral skin entry
site performed by the nephrologist. This did not adversely effect performance of laparoscopy. In all
patients the peritoneal dialysis catheter was strangled by the omentum and was pulled to right upper
quadrant. None of the patients required a second surgery or replacement of the catheter after first
laparoscopic intervention. There was not any complication related to surgical intervention. All
patients were discharged the same day.
Conclusion: Laparoscopic revision of peritoneal dialysis catheter is an effective way of managing
dysfunctioning catheters. Catheter tip should be searched in right upper quadrant and should be
cleaned thoroughly. Three trocars are enough for the intervention. Stitching of the catheter to the
peritoneum seems to be preventing the re-location of the catheter tip secondary to misplaced
catheter body. Low flow irrigation after surgery is of paramount importance to prevent clogging of
the holes on catheter.

P530
Indications and Surgical Results of Pressurized Intraperitoneal
Aerosol Chemotherapy (PIPAC) for Palliative Therapy
of Peritoneal Metastasis After 748 Consecutive Procedures
Marc A Reymond, MD, Cedric Demtroder, MD, Jurgen Zieren, MD,
Urs Giger-Pabst, MD, Dirk Strumberg, MD, Clemens B Tempfer,
MD, Ruhr-University Bochum
Objective of the Study: Peritoneal metastasis has a dismal prognosis and better therapies are
urgently needed. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally-invasive therapy distributing chemotherapy as a pressurized aerosol into the abdominal cavity during
laparoscopy. Superior drug delivery into peritoneal tissue has been demonstrated. Objective was to
determine indications, patient characteristics, operating time, intraoperative and postoperative
surgical complications and hospital mortality.
Methods and Procedures: Single center study. Prospective registry data, retrospective analysis.
PIPAC includes following steps: 1) installation of a 12 mmHg capnoperitoneum; 2) staging
laparoscopy with multiple biopsies; 3) aerosolization of low-dose chemotherapy (oxaliplatin
92 mg/m2 body surface for colorectal and appendiceal cancer; cisplatin 7.5 mg/m2 combined with
doxorubicin 2.5 mg/m2 for all other indications) using a dedicated micropump driven by an
industry-standard injector; 4) steady state for 30 min. application time at 37 C; 5) exsufflation of
the toxic aerosol over a closed aerosol waste system (CAWS). The operating room is equipped with
laminar airflow. Chemotherapy application is remote controlled.
Results: Between 5/2013 and 9/2015 748 PIPAC were scheduled in 336 consecutive patients (219
females, 117 males) with peritoneal metastasis; mean age 60.2 11.6 years; [2.2 PIPAC/patient;
max. 8 PIPAC/patient). Indications were ovarian (40 %), gastric (19 %) and colorectal cancer
(15 %), CUP (7 %), HBP (6 %) and appendiceal tumors (5 %), mesothelioma (5 %) and others
(3 %). 92.6 % patients had received previous chemotherapy. No patient was eligible for CRS and
HIPEC. No patient had extraperitoneal metastasis. PCI was 15 11.6. Ascites volume was
582 1273 ml. In 91 cases (12.2 %) abdominal access was not possible due to adhesions. 655
PIPAC and 11 PITAC (intrathoracic application) were performed. Mean operating time was
84 min. There were 5 access lesions (bowel perforations), one of them remained undetected, 4 were
immediately repaired. No further intraoperative complication was noted. There was no postoperative bowel perforation. In 4 cases, a parietal hematoma developed. Median postoperative hospital
stay was 3 days. Hospital mortality was 2 (0.3 %): peritonitis = 1; tumor lysis syndrome = 1).
Conclusions: Most common indication for PIPAC is platin-resistant, recurrent ovarian cancer,
followed by gastric and colorectal cancer. PIPAC can be performed in 9/10 cases in spite of
peritoneal adhesions and can be repeated up to 8 times in the same patient. Abdominal access is the
critical step of the procedure. PIPAC does not induce chemical bowel perforations. PIPAC is safe
and surgical complications are rare.

Introduction: Bilateral axillo-breast approach (BABA) surgery was first introduced in 2004. This
surgical technique is useful in the endocrine operation such as sistrunk operation and parathyroidectomy as well as thyroidectomy due to its excellent magnification and symmetrical view. We
report the initial experience of endoscopic and robotic BABA parathyroidectomy.
Patients: Five patients who was diagnosed with a primary hyperparathyroidism were studied. All
patients underwent endoscopic and robotic parathyroidectomy by bilateral axillo-breast approach
from July 2012 to January 2015. Data collected included patients demographics, operative time,
complications, and outcome. Three patients were females (60 %) and the median age was 44 years.
Results: Three patients underwent endoscopic BABA parathyroidectomy and two patients received
a robotic BABA parathyroidecomy. All patients were diagnosed with primary hyperparathyroidism
with a single parathyroid lesion. The mean level of preoperative PTH and iCa were 608.9 pg/mL
(82.3 * 1931.1) and 1.63 mmol/L (1.4 * 1.88). The mean level of postoperative PTH and iCa
were 23.14 pg/mL (6.9 * 39.8) and 1.28 mmol/L (1.13 * 1.56). There were no operation-related
complications. The mean operation time was 127 minutes. The patient was discharged from the
hospital in 3 days after surgery.
Conclusion: Endoscopic and robotic BABA parathyroidectomy for primary hyperparathyoridism
can be a technically feasible and safe procedure with cosmetic advantage.

P532
Single-Port Laparoscopic Appendectomy is Quicker than MultPort Laparoscopic Appendectomy: A Study of the Learning
Curve
Sarah Eapen, MD1, Terry Carman, MD2, Charudutt Paranjape, MD,
FACS2, 1Northside Medical Center, 2Akron General Medical Center
Objective: The learning curve of single-port surgery has been recognized as a barrier to its use in
the treatment of acute appendicitis. We investigate the learning curve of our single-surgeon, highvolume experience with single-port laparoscopic appendectomy and compare it with multi-port
laparoscopic appendectomy in this study.
Methods and Procedures: A retrospective review of operative time, appendicitis severity, and
postoperative complications was conducted for 128 single-surgeon, single-port laparoscopic
appendectomies (SPLA) and 941 multi-port, multi-surgeon laparoscopic appendectomies (MPLA)
performed at Akron General Medical Center from April 2009 to December 2014. Statistical
analysis was performed using Fishers test and t test.
Results: Patient demographics, body mass index, and advanced appendicitis rates were comparable
between the two groups. From 2009 to 2011, there was no difference in operative time between
SPLA (n = 58) and MPLA (n = 422). SPLA operative time was consistently and significantly
shorter in 2012 (32.7 18.2 minutes; p = 0.0016), 2013 (29.3 6.7 minutes; p = 0.0037), and
2014 (38.5 18.8 minutes; p = 0.0145) and improved from the beginning of the study in 2009
(55.1 17.5 minutes) to the end in 2014 (38.5 18.8 minutes; p = 0.0232). Overall, SPLA
operative time was shorter (38.4 19.0 minutes) compared to MPLA (46.1 19.2 minutes;
p = 0.0001). There were no differences in postoperative complications including ileus, urinary
retention, deep space infection, incisional hernia, and thirty-day readmission.
Conclusions: Our study strongly supports the use of SPLA in the treatment of acute appendicitis
and suggests the associated learning curve can be safely overcome. After approximately 58 cases,
SPLA technique can be mastered to achieve operative time superior to MPLA without compromising safety.

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P533

P535

Conventional Laparoscopic vs. Laparo-Endoscopic Single Site

(Less) Heller Myotomy: Is Less More?

Exploration of Different Single Incision Laparoscopic Operations

for the Resection of Gastric Stromal Tumors

Sharona B Ross, MD, Darrell J Downs, ATC, Janelle Spence, BS,

Mark Giorgi, Christian B Rodriquez, BS, Indraneil Mukherjee, MD,
Alexander S Rosemurgy, MD, Florida Hospital Tampa

Kong Jing, MD, Wu Shuo-dong, Shengjing Hospital of China

Medical University

Introduction: Laparoscopic Heller myotomy is a first-line treatment for patients with achalasia.
The evolution of laparoscopy has allowed laparoscopic Heller myotomy to be undertaken through a
single 12 mm umbilical incision, Laparo-Endoscopic Single-Site (LESS) surgery. Because it is a
scarless approach, LESS surgery has the potential to significantly improve cosmetic outcome
and patient satisfaction after myotomy. This study was undertaken to compare a single institutions
experience with conventional laparoscopic vs. LESS Heller myotomy.
Methods: With IRB approval, 635 patients have been prospectively followed since 1991 after
Heller myotomy; we compared outcomes after conventional laparoscopic vs. LESS myotomy,
excluding 45 patients undergoing esophageal diverticulectomy. Patients scored the frequency and
severity of their symptoms before and after myotomy using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients were queried before myotomy about their
greatest postoperative priorities and after myotomy about their scar satisfaction (1 = revolting to
10 = beautiful). Data are presented as median or median (mean SD), where appropriate.
Results: 432 patients underwent conventional laparoscopic myotomy and, more recently, 158
consecutive patients underwent LESS myotomy. 52 % of patients were men; median age was
49 years and BMI was 24 kg/m2 for all patients. Prior to Heller myotomy, patients noted many
frequent and severe symptoms (Table 1). Before LESS myotomy, patients scored safety as their
greatest priority, with the appearance and size of the scar and postoperative pain following
thereafter. Heller myotomy ameliorated the frequency and severity of symptoms (Table 1). Relative
to conventional laparoscopy, patients who underwent LESS myotomy had similar symptom
amelioration without developing new symptoms (e.g., heartburn) (Table 1), but had a shorter
hospital LOS at 1 (2 days 3.0) vs. 1 (3 days 7) (p \ 0.05). Median scar satisfaction for
patients undergoing LESS myotomy was 10. Patient satisfaction after conventional laparoscopic
and LESS Heller myotomy was at 84 %.
Conclusions: Heller myotomy, regardless of approach, provides efficacious, satisfactory, and
durable palliation of achalasia; symptom resolution and patient satisfaction support its continued
application. The LESS approach provides the same salutary benefits as the conventional laparoscopic approach with the additional benefits of shorter hospitalization and improved cosmesis
through outstanding scar satisfaction. Ultimately, there is more gain associated with LESS
Heller myotomy than there is with conventional laparoscopic Heller myotomy, thereby promoting
its application.
Table 1

Introduction: GISTs are potentially malignant tumors and clinical practice guidelines for
GISTs recommend surgical resection if it can be completely resected. In recent years,
transumbilical single-incision laparoscopic surgery (SILS) partial gastrectomy, although
still in its initial stages, has been performed increasingly often for resection of small GISTs
because of its cosmetic advantage. However, the tumors larger or the tumors located at the
cardia or pylorus, proximal or distal gastrectomy, rather than partial gastrectomy was
considered needed. The authors reported the new technique of umbilical single-incision
laparoscopic surgery (SILS) and explored the different operations in the treatment of
gastrointestinal stromal tumors (GISTs) of the stomach with conventional laparoscopic
instruments.
Methods: Data of 34 gastric GISTs who had SILS treatment were analyzed retrospectively
at Shengjing Hospital of China Medical University between December 2009 and February
2014.
Demographic data, operative details, recovery parameters, and details of the specimen were
obtained and analyzed based on the information obtained from the medical records. The
location of tumor was evaluated by preoperative CT and EUS, also it was confirmed during
the operation. Tumor size, grade and malignant risk were evaluated by pathology.
Results: SILS partial gastrectomy was performed in 27 patients, the mean size of the
tumors was 2.6 cm (0.66.5 cm), the mean operating time was 95 min, the average blood
loss was 47 ml.
SILS distal gastrectomy was performed in 4 cases with the tumor located near pylorus and
larger than 2 cm. Also distal gastrectomy was performed in 2 patients with tumor 8.5 and
10 cm respectively. Among these 6 patients, 5 cases used BII Gastric jejunum anastomosis
and 1 case gastric-duodenal triangular anastomosis. The mean size of the tumors was
6.6 cm (3.510 cm), the mean operating time was 240 min, the average blood loss was
216 ml.
Subtotal gastrectomy and combined organ resection in 1 cases.
There were no intraoperative or postoperative complications experienced in all the patients
except one postoperative intraperitoneal bleeding and one incision infection.
Conclusion: SILS for GISTs is a feasible and safe technique when performed by experienced laparoscopic surgeons. Suitable SILS operations should be selected for GISTs
according their different size and location.
Keywords: Gastric stromal tumor; Laparoscopic; SILS; Partial gastrectomy; Subtotal
gastrectomy

P536
A Novel Abdominal Wall-Lifting Device for Gasless Laparoscopic
Gastrectomy: The Initial Experience of a Serial Cases

P534
Laparoscopic Nissen Fundoplication: Analysis of Preoperative
Risk Factors And 30-Day Morbidity and Mortality Using ACSNSQIP
E Miller, MD, J O Bader, Phd, D B Holt, MD, FACS, William
Beaumont Army Medical Center
Introduction: Controversy exists whether laparoscopic Nissen fundoplication (LNF) has lower
morbidity and mortality when performed in high volume centers as well as whether the procedure
should be performed by general surgeons or sub-specialists. We sought to identify pre-operative
risk factors associated with increased 30-day morbidity and mortality for patients undergoing LNF
in order to delineate which patients may be better suited for high volume centers and/or subspecialty care.
Methods and Procedures: 16,107 LNF were identified using Current Procedural Terminology
(CPT) 43280 from the 20052013 National Surgical Quality Improvement Program (NSQIP)
database. Patient demographics, preoperative characteristics, and 30 day morbidity and mortality
data were analyzed. Univariate, chi-squared, and multivariate logistic regression analysis were used
to examine the influence of risk factors on 30-day overall complications and mortality.
Results: Overall 30-day morbidity and mortality for LNF was 3.6 % and 0.2 % respectively.
Unplanned intubation (0.6 %), urinary tract infection (0.9 %), and pneumonia (0.9 %) were the
most common complications. Patients with renal failure on dialysis, ASA 3 or greater, sepsis within
48 hours prior to surgery, chronic steroid use, and bleeding requiring transfusion had odds ratios of
27.93 (4.44175.81, p = 0.0004), 3.39 (1.189.78, p = 0.02), 9.89 (2.6836.49, p = 0.0006), 3.62
(1.1911.07, p = 0.02) and 13.54 (4.0145.65, p = \0.0001) for associated mortality respectively.
Mean operative time was 129.5 63.3 minutes. Increased operative time greater than 1 standard
deviation above the mean was associated with increased complications but not overall mortality on
multivariate logistic regression.
Conclusion: LNF has a low overall mortality rate. The general surgeon should be able to safely
perform LNF in appropriately selected patients in less than 3.2 hours. Patients with renal failure,
ASA 3, preoperative sepsis, and chronic steroid use should be carefully selected and counselled for
the procedure and may be considered for referral to high volume centers.

123

Jianxin Cui, Canrong Lu, Hongqing Xi, Yingwen Cai, Shibo Bian,
Liangang Ma, Yunhe Gao, Bo Wei, Lin Chen, Department of General
Surgery, Chinese Peoples Liberation Army of General Hospital
Background: Open surgery for gastric cancer (GC) can cause serve surgery-related injury,
and CO2 pneumoperitoneum laparoscopic surgery may bring CO2-related complications,
such as respiratory and circulatory system complications. Though reducing these adverse
effects, present gasless laparoscopic techniques doesnt suit for complicated abdominal
surgery due to inadequate operative space. Therefore, we developed a novel abdominal
wall-lifting device for gasless laparoscopic gastrectomy.
Methods: We described a novel self-designed abdominal wall-lifting device using in
gasless laparoscopic gastrectomy. We performed this gasless technique in three pigs to
verify its feasibility and performed it in ten old patients with advanced GC, recording and
analyzing the operation factors and short-term outcomes.
Results: Three pigs underwent laparoscopic gastrectomy using the device with satisfactory
operative space and no conversion to open operation. Ten GC patients, with a mean age of
75.8 years and mean BMI of 23.3 kg/m2, underwent laparoscopic gastrectomy using this
gasless technique. The operation time, intraoperative blood loss, times of wiping the lens,
harvested lymph nodes were 218.9 47.9 min, 210 52.3 ml, 3.6 0.9, 35.1 4.6
separately. The time of first flatus was 2.8 0.75 days and the length of postoperative
hospital stay was 8.5 1.6 days. There were no conversion and massive hemorrhages,
related injuries or other complications during the operation.
Conclusions: These preliminary outcomes indicate that this novel abdominal wall-lifting
device could provide sufficient exposure for gasless gastrectomy technique, which can
hybridize the advantages of both the traditional open resection and laparoscopic surgery.
Key words: Instrument design; Gasless laparoscopic gastrectomy; Innovation

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P537

P539

Minimally Invasive Right Hemicolectomy for Kyphotic Patients

Examination of Staging Laparoscopy for Advanced Pancreatic

Cancer

Si-Yuan Yao, MD, Atsushi Ikeda, MD, Teppei Murakami, MD, PhD,
Eiji Tanaka, MD, PhD, Tatsuo Okumoto, MD, PhD, Kobe City
Medical Center West Hospital
Abdominal surgery in patients with severe kyphosis is still a challenge for surgeons because
of their altered habitus However, less invasive surgery should be also considered to these
patients. To overcome the difficulties, we introduced umbilical single incisional approach
plus one port for right hemicolectomy and achieved good perioperative outcomes.

P538
Reduced Port Laparoscopic Cholecystectomy Maintains Safety
and Feasibility
Kan Tanabe, MD, Shinichiro Mori, PhD, Kenji Baba, Yoshiaki Kita,
Masayuki Yanagi, Kousei Maemura, Hiroshi Kurahara, Yuko Mataki,
Hiroyuki Shinchi, Fumio Kijima, Shoji Natsugoe, Department
of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima
University School of Medicine
Objective: Laparoscopic cholecystectomy (LC) has become a standard surgical treatment
for the patients with benign disease of gallbladder. Reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a
cosmetic benefit for selected patients. The aim of this study was to evaluate safety and
feasibility of reduced port LC in our institutions.
Methods: Between July 2009 and June 2013, 59 patients who underwent reduced port LC
for benign disease of gallbladder were included (17 male and 42 female, age: 55.8 years
old, 23 cases were single-incision LC and 36 cases were double-incision LC). The outcomes
were evaluated in terms of operation time, intraoperative blood loss, incidence of conversion to open surgery, incidence of additional port and perioperative complications.
Sugical Procedures: The patients were placed in the broad base and the operator stood
between the legs. An access device with the wound-protector was inserted through an
umbilical skin incision. Two 5-mm trocars were placed through access device for a 5-mm
laparoscope and 5-mm instrument. Pneumoperitoneum was maintained at 10 mmHg using
CO2. We added one port into the right flank and one needle puncture into the epigastrium
for double-incision LC. A flexible laparoscope was inserted from access device port. The
serosa of the gallbladder was dissected using an Electric cautery. And the Calots triangle
was dissected free of all tissue except for the cystic duct and artery using the ultrasonic
laparoscopic coagulation shears, and the cystic plate was exposed. After this view was
achieved, the cystic duct and artery were dissected with clips. The gallbladder was then
removed through the wound-protector of umbilical incision. We cut cystic duct after
confirmed the critical view of safety for all patients.
Results: Reduced port LC was performed in 17 patients with chronic cholecystitis, 39 with
gallbladder stone with symptoms, and 3 with adenomyomatosis of gallbladder. The mean
operative time was 114.3 minutes, the mean blood loss was 4.2 ml. There was one (1.7 %)
conversion to open surgery. One (1.7 %) patient received 3 additional ports, 4 (6.8 %) other
patients received one additional port. 5 patients (8.5 %) experienced intraoperative complications, gallbladder injury (n = 4) and bleeding (n = 1). One patient experienced
surgical site infection. There was no severe intraoperative and postoperative complications.
Conclusion: Our experience and surgical technique suggest that reduced port LC for the
patients with benign disease of gallbladder is a safe and feasible procedure.

Yuko Mataki, PhD, Kosei Maemura, Hiroshi Kurahara, Yota

Kawasaki, Keiichi Yonemori, Masahiko Sakoda, Satoshi Iino, Koji
Minami, Shinichi Ueno, Hiroyuki Shinchi, Shoji Natsugoe,
Kagoshima University
Introduction: In advanced pancreatic cancer, it is very important to perform an accurate
diagnose such as peritoneal disseminations liver metastasis for selection of an appropriate
treatment. In this report, the advanced pancreatic cancer who underwent laparoscopic
examination at our department were retrospectively analyzed.
Cases: the 82 cases of examination laparoscopic cases for advanced pancreatic cancer,
which was performed between 2005 and 2015. In all cases, malignancy was pathologically
identified by FNA under EUS, tissue biopsy by laparoscopic findings or ERCP. Gender was
50 male and 32 female, average age 65 year (4183), tumor location is pancreatic head for
57, pancreatic body 23, pancreatic tail two cases. According to TNM classification, stage III
is 66 cases, IV is 16 cases, performance status 0 is in 71 cases, 1 was in 11.
Method: Preoperative imaging diagnosis were performed by MDCT, EOB-MR, abdominal
US and FDG-PET, those were compared with laparoscopic findings
Result:
1. Patients without distant metastasis at the preoperative diagnosis has had 70 cases. Among
them, distant metastasis were pointed out in eight cases by staging laparoscopy. PER (+) is
in seven cases (one example only cytology), HEP (+) was in one example. Those location of
main tumor was pancreatic head in three cases, pancreatic body in five cases.
2. In the preoperative image, HEP (+) is in eight cases, PER (+) is in three cases, both HEP
(+) and PER (+) but was in one case. In the examination of laparoscope, HEP (+) was
detected among the eight cases, HEP + is four cases, PER + is three cases, remaining one
example HEP, PER were both negative. PER (+) in 3 patients had all histologically PER
(+).
3. The resection of liver metastasis and peritoneal dissemination were underwent by staging
laparoscopy (including small laparotomy) in 13 cases, and biopsy of the primary lesion was
underwent in 27 cases. Although admitted pancreatic fistula of Grade B in one cases, there
were no other complications.
Conclusions: By laparoscopic examination in advanced pancreatic cancer who had preoperatively no detection of distant metastasis, we could detect the distant metastases in
about 10 %, Moreover, we can collect some tissue of the distant metastasis, staging
laparoscopy is very useful method for planning therapy.

P540
Single Incision Laparoscopic Cholecystectomy
Nihat Yavuz, MD1, Serkan Teksoz, MD2, Engin Hatipoglu, MD2,
Sabri Erguney, MD2, Tuna Yildirim, MD1, Sirri Ozkan, MD1,
1
Acibadem Kadikoy Hospital, General Surgery Department, 2Istanbul
University, Cerrahpasa Medical School, General Surgery Department
Introduction: Thanks to technological advances, laparoscopic surgery continues to evolve.
One recent advance in this field is laparoscopy performed through a single incision. In this
study we present our experiences concerning cholecystectomy through a single incision.
Materials and Methods: Between November 2009 and September 2015 we performed
single incision laparoscopic cholecystectomy in 505 patients.335 of the patients were
female, 170 were male. The mean age was 44 years (range: 779 years). 44 patients presented with acute cholecystitis, others with cholelithiasis. In 12 cases an ERCP had been
performed preoperatively. The procedures were realized using a SILS portTM (COVIDIEN), flexible and articulated instruments (COVIDIEN) and 5 mm endoclip as the
ligation device (COVIDIEN) and electrocautery as the energy source
Results: Average operative time was 33 minutes (20240 minutes). An additional trocar
was inserted in 13 cases, because of difficulty at exploration in 10, for bleeding control in
two and because of a choledocal cyst in one other case. An abdominal drain was used in 24
cases, which had been removed the following day. No conversation to laparoscopic or
conventional surgery. Postoperative complications occurred in 13 cases:Bile leakage due to
accessory bile duct in one case, wound problems (seroma and infection) in 10 cases and
hernia in two cases. Nonsteroid antiinflammatory agents had been used for postoperative
analgesia. Mean hospital stay was 1.02 day (range: 13 days).
Conclusion: With its superiority of scarlessness, single port laparoscopic cholecystectomy
may be admitted as an alternative method to its multiport counterpart

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Table 2 .

Cardia-Preserving Combined Endoscopic/Laparoscopic

Intragastric Resection of Proximal Gastric Submucosal Tumors
Xianlin Han, MD, Weiming Kang, MD, Zhiqiang Ma, MD, Xin Ye,
MD, Jianchun Yu, MD, Peking Union Medical College Hospital
Introduction: This study evaluated the feasibility, security and surgical outcome of the combined endoscopic/laparoscopic intragastric resection of gastric tumors through anterior incisional mode. The gastric submucosal masses includes benign tumors (eg,
lipoma and leiomyoma) and potentially malignant tumors (eg, Gastric stromal tumor). It will increase the difficulties and risks of the
procedure, if the tumor is located in the posterior wall of proximal stomach body and fundus. This modified operation mode can
maximally fulfill the potential of preservation of cardia, which means much better quality of life and much better prognosis to
patients with proximal submucosal gastric tumors.
Methods: 9 patients in total were admitted from February to July in early 2015. All the tumors, which ranges from 1.0 cm 9 1.0 cm
to 6.0 cm 9 6.0 cm, were located proximally on the posterior wall of stomach body and fundus. All the operations were performed
in the gastric lumen using laparoscopic instruments with gastroscope monitoring, and the tumors were all resected by intragastrically
incising the anterior gastric wall.
Results: All the tumors were resected completely with cardia preservation, all with final pathology demonstration. The mean
operation time was 168.5 minutes, with less than 150 ml blood loss and no peritoneotomy conversion. 1 patient was with postoperational seroperitoneum and pleural effusion, and treated well with CT guided interventional therapy. No postoperational
complications happened in the other 8 patients. All the patients were discharged in 3 to 9 days, with no postoperational evaluation of
gastric motility and esophageal manometry. 6 patients with GIST had pathological demonstration, which the immunehistochemical
staining were 100 % positive for CD34 and 83 % positive for CD117. For 3 leiomyoma tumors, all were positive for SMA.
Conclusions: The combined endoscopic/laparoscopic gastric fundus tumor intragastric resection highly proved to be feasible, safe
and effective treatments for proximal gastric submucosal patients. All the patients have complete or partial cardia preservation,
which indicates better patient prognosis and higher life quality.
Keyword: Cardia-preserving; Laparoscpy; Endoscopy;Submucosal tumor

Table 3 .

P542
Is Distal Revision of Ventriculo (Lumbo)-Peritoneal Shunts
Worth It? A 20-Year Single Center Experience
Maitham A Moslim, MD, Gautam Sharma, MD, Hideo Takahashi,
MD, Andrew Strong, MD, Mena Boules, MD, Villamere James, MD,
ORourke Colin, Steven Rosenblatt, MD, Rodriguez John, MD, Kroh
Matthew, MD, Cleveland Clinic Foundation
Introduction: Laparoscopic-assisted revision of ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts is an ubiquitous procedure for post-shunt abdominal pain. Complications related to the abdominal portion of the procedure can be managed
laparoscopically. The aim of this study is to report a single center experience with laparoscopic distal revision of VP and LP shunts,
assessing the resolution of catheter related abdominal symptoms.
Methods: With IRB approval, all patients who underwent distal revision of VP and LP shunts between 1994 and 2014 were
evaluated. The indications for revision, post-operative course, complications and follow-up were documented. Analyses were done
using R version 3.2.1.
Results: 259 patients underwent distal revision. The indications for revision were: malfunction 49 %, infection 21.6 %, abdominal
pain 16.5 %, and others 12.9 %. Patients who presented with abdominal pain (n = 53) were studies. All revisions were performed
on the distal (peritoneal) portion of the catheter; VP to VP, LP to LP and LP to VP (77 %, 17 % and 6 %, respectively). The surgical
approach was open, laparoscopic and laparoscopic converted to open (8 %, 90 % and 6 %, respectively). Resolution of abdominal
pain was documented in 71.7 % of cases, including subsequent revisions (Table 1).
Early post-operative complications included (\30 days): Pain 63 %, malfunction 23 %, and surgical site infection 14 % (n = 3).
Late complication rates were: pain 35 %, malfunction 30 % and infection 27 % (Table 2). Early post-operative pain was more
common in patients who presented with pain for revision (35 % vs 18 %, P = 0.013) (Table 3).
Subsequent revision was performed in 22 patients with total of 53 revisions; median 2 [IQR = 31]. Common indications were
infection (n = 21), malfunction (n = 17) and abdominal pain (n = 8).
With the initial presentation of abdominal pain; the odds of having an early post-operative malfunction, a long-term complication
and a larger number of revisions are estimated to be 0.6 (95 % CI 0.14.1), 19.2 (95 % CI 3.2114.9) and 1.6 (95 % CI 0.64.1)
folds higher for patients without resolution of initial symptoms than for those with resolution; respectively (Figs. 1, 2, 3).
The median postoperative length of hospitalization was 1 [IQR = 10] day. The median follow up is 40 [IQR = 6521] months.
Conclusions: The study has demonstrated that patients who present with abdominal pain for distal revision of VP/LP catheter are
more inclined to have early postoperative abdominal pain and long-term complications with persistence of pain.

Fig. 1 .

Table 1 .

Fig. 2 .

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P545

Intracorporeal Hand-Sewn Esophagojejunal Anastomosis During

Laparoscopic Total Gastrectomy for Gastric Cancer

Totally Laparoscopic Treatment of Colonic Obstruction Due

to Colon Cancer in 71 Patients: Texas Endosurgery Institute
Experience

Rodrigo Munoz, MD, PhD1, Enrique Norero, MD2, Manuel Manzor,

MD1, Eduardo Briceno, MD2, Mauricio Gabrielli, MD1, Nicolas
Quezada, MD1, Marco Ceroni, MD3, Paulina Gonzalez, RN3,
Fernando Crovari1, 1Department of Digestive Surgery, Pontificia
Universidad Catolica de Chile, 2Department of Digestive Surgery,
Pontificia Universidad Catolica de Chile/Hospital Sotero del Rio,
3
Department of Digestive Surgery, Hospital Sotero del Rio
Introduction: Laparoscopic total gastrectomy (LTG) to treat gastric cancer has gained popularity over the
recent years due to its benefits associated with a minimally invasive approach, and due to its oncological
results comparable to those observed after open total gastrectomy. However, performing the esophagojejunal anastomosis (EJA) is technically difficult and remains a major source of serious postoperative
complications, such as leakage.
Objectives: To describe the surgical technique and report our preliminary experience with a new method of
EJA for the reconstruction after LTG for gastric cancer.
Methods: We identified patients that underwent laparoscopic total gastrectomy for gastric cancer in two
centers from 20122015, with a standard esophagojejunal anastomosis technique. Briefly, our reconstruction
technique consisted of a Roux-en-Y, with a two layer intracorporeal hand-sewn EJA anastomosis using a
34Fr or 50Fr bogie. An upper GI series study was performed to rule out leakage before the beginning of
enteral feeding.
Results: We identified 41 patients, 21 (51.2 %) were female, with an average age of 62 12 years. The
average operation time and EJA was 338 64 minutes, 53 16 minutes, respectively. Average intraoperative bleeding was 196 129 ml. There were no conversions related to intracorporeal EJA. There were
no patients with Clavien III or higher complications. Postoperative morbidity was observed in three (7,3 %)
patients. There was no mortality and no reoperations. Median length of stay was 8.5 (729) days. There were
two (4,9 %) cases of EJA leakage.
Conclusions: Intracorporeal hand-sewn esophagojejunostomy appears to be a safe and a technically feasible
technique without the use of mechanical suturing devices. This technique also avoids the need of any upper
abdominal incision, thus maintaining the benefits of minimally invasive approach.

P544
Fluorescent Insicionless Cholangiography as a Teaching Tool
for Identification of Calots Triangle Subtitle: Fluorescent
Cholangiography in a Residency Program
Mayank Roy, MD, Fernando Dip, MD, David Nguyen, MD, Conrad
Simpfendorfer, MD, FACS, Emanuele Lo Menzo, MD, PhD, FACS,
FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J
Rosenthal, MD, FACS, FASMBS, Cleveland Clinic Florida
Introduction: Intra-operative incisionless Fluorescent cholangiogram (IOIFC) has been demonstrated to be
a useful tool to increase the visualization of the Calots triangle. This study evaluates the identification of
extra-hepatic biliary structures with xenon and near infrared (NIR) light by medical students and surgery
residents.
Method: A picture with xenon light as well as with NIR light at the same stage of Calots triangle dissection
was taken from 10 different cases of laparoscopic cholecystectomy (LC). All 20 pictures were organized in a
random fashion to remove any imagery bias. 20 students and 20 residents were asked to identify the biliary
anatomy.
Results: Medical students were able to accurately identify the cystic duct on an average 33.8 % under the
xenon light vs 86 % under the NIR light (p = 0.0001), the common hepatic duct on an average 19 % under
the xenon light vs 88.5 % under the NIR light (p = 0.0001) and the junction on an average 24 % under
xenon light vs 80.5 % under the NIR light (p = 0.0001). Surgery residents were able to accurately identify
the cystic duct on an average 40 % under the xenon light vs 99 % under the NIR light (p = 0.0001), the
common hepatic duct on an average 35 % under the xenon light vs 96 % under the NIR light (p = 0.0001)
and the junction on an average 24 % under the xenon light vs 95.5 % under the NIR light (p = 0.0001).
Conclusion: For a given reader level, IOIFC increases the visualization of the Calots triangle structures
when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

Miguel A Hernandez, MD, Morris E Franklin Jr., MD, FACS, Jeffrey

L Glass, MD, FACS, Mark Glover, MD, Ekong Uffort, MD, Bryson
Nicholson, MD, Texas Endosurgery Institute
Background: Several treatment options for colonic obstruction are available. Loop
colostomy, Hartmanns procedure, one stage surgery, and colonic stenting have been
selected as options for the management of colonic obstruction. The choice of treatment
depends upon patients characteristics, disease presentation, and preference of the surgeon
as well. Laparoscopic approach has gained more and more popularity on colorectal surgery
field. The objective of this study is to demonstrate the feasibility and safety of laparoscopic
approach in patients with colonic obstruction caused by colon cancer.
Material and Methods: We designed a nonrandomized prospective study of all consecutive patients with obstructive colonic tumors. We recollected data from April 1992 to
September 2015 and were analyzed.
Results: Laparoscopic successfully treatment was in 69 patients of 71. Of these patients 25
were females and 46 were male. The site of cancer was: 20 cecum cancer, 4 transverse
colon cancer, 7 descending colon cancer, 24 sigmoid colon cancer, and 16 rectal cancer. We
performed 21 right hemicolectomies, 4 transverse colon resections, 7 left hemicolectomies,
20 sigmoid colon resection, 10 low anterior resection, 7 Hartmanns procedure, and 2
laparotomies due to severe colon dilatation and multiple adhesions caused by multiple prior
surgeries.
Conclusions: In experienced hands, colonic obstruction due to malignant disease can be
safely and effectively treated by laparoscopic approach. Current trends toward minimally
invasive surgery have allowed us to take better and safer measures to provide patients with
the best possible medical and surgical care. In our perspective, laparoscopic surgery for
obstructive colonic cancer offers the patient the known benefits of laparoscopic surgery and
a safe option for this disease.

P546
Small Bowel Obstruction Caused by Single Adhesive Band:
Laparoscopic Operative Treatment Should Take Priority Over
Non-Operative Treatment
Yoo Shin Choi, MD, Suk Won Suh, MD, Chung-Ang University
Background: Small bowel obstruction (SBO) is a frequent cause of emergency surgical
admission. Most surgeons advocate a trial of non-operative treatment (NT), but others favor
operative treatment (OT) because of the high recurrence, morbidity and mortality rate
associated with delaying surgery. We compared the postoperative outcomes of the two
groups (OT and NT) to evaluate a better result for SBO, especially, caused by single
adhesive band.
Methods: Among the total 62 patients, 16 were in the OT group (operated by laparoscopy)
and 46 in the NT group. Early (duration of hospital stay, time to flatus, oral intake and
defecation after start of treatment, as well as morbidity and mortality) and late postoperative
outcomes (the recurrence rate, the time interval between discharge and recurrence of SBO)
were evaluated.
Results: The times to first flatus, oral intake and defecation after treatment were significantly shorter in the OT group (p = 0.030, 0.033 and 0.024). The recurrence rate was
significantly lower in the OT group than in the NT group (6.2 vs. 32.6 percent, p = 0.038).
The time from discharge to first recurrence was significantly longer in the OT group than in
the NT group (172 vs. 104.6 26.5 days, p = 0.027).
Conclusions: SBO with single adhesive band is not effectively treated by NT, however, OT
has notable success if the surgery is performed early. Therefore, patients presenting with
SBO especially, caused by single adhesive band can be initially managed with laparoscopic
OT.

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P549

laparoscopic Pancreaticoduodenectomy For Duodenal GIST

1

Jia-Yu Zhou, MD , Wei-Wei Jin, MD , Yi-Ping Mou, MD , Xiao-Wu

Xu, MD2, Ren-Chao Zhang, MD2, Yu-Cheng Zhou, MS2, Chao-Jie
Huang2, Chao Lu1, Rong-Gao Chen1, Jing-Rui Wang1, 1Zhejiang
University, 2Zhejiang Provincial People Hospital
Background: The incidence of duodenal location of stromal tumors is rare. The optimal
surgical procedure for GISTs has not been well characterized. The aim of this study is to
describe perioperative and follow-up outcomes of laparoscopic pancreaticoduodenectomy
(LPD) for Duodenal GIST.
Material and Methods: From January 2013 to September 2015, there were 13 patients
with duodenal GIST received LPD in a single institution. All the medical record were
retrospectively reviewed. Demographic data, clinicopathological features, surgical outcomes, postoperative complications, mortality and follow-up results were prospectively
recorded.
Results: In the study, 13 patients underwent LPD for duodenal GIST, 5 male and 8 female,
with a median age of 59 years old. Patients presented with gastrointestinal bleeding (n = 6,
46.16 %), Incidentally found (n = 3, 23.08 %), abdominal mass (n = 2, 15.38 %),
abdominal pain (n = 1, 7.69 %), and GI Obstruction (n = 1, 7.69 %). The tumors originated in the first to fourth portion of the duodenum were 23.10 %, 38.46 %, 23.10 % and
15.34 %, respectively. The mean size of tumor was 5.6(3.08.4) cm. Median operative time
was 375 min and median blood loss was 185 ml. Based on the NIH risk criteria, patients
exhibited low risk (n = 4 30.77 %), intermediate risk (n = 3 23.08 %), and high risk
(n = 6 46.15 %). All the surgical margins were negative (R0 resection). Median postoperative hospital stay was 10 days. Overall 30-day morbidity rate was 56 % (48 % Clavien 2
or less). No mortality has been found. During a follow-up of 19 (232) mo, the 1-year and
2-year recurrence/metastasis-free survival rates was 100 % and 86 %, respectively. In this
study, 9 of 13 patients received postoperative adjuvant imatinib, and one of them developed
multiple liver metastasis within one year after the operation due to stop taking imatinib.
Conclusions: Laparoscopic pancreaticoduodenectomy is a safe, feasible and effective
surgical procedure for duodenal GIST.

Single Incision Laparoscopic Cholecystectomy Without any

Special Port or Roticulating Laparoscopic Instruments: Are We
Kidding?
Nitin Jha, MBBS, MS, FIAGES, FAIS1, Sanjay Chaurey, MBBS, MS,
FIAGES2, 1FORTIS & PSRI HOSPITAL, DELHI-NCR, 2PSRI
HOSPITAL, DELHI
Introduction: Laparoscopic cholecystectomy has undergone enormous changes after advent of
SILS. There are numerous studies showing equal risks and better cosmetic outcomes with SILS.
The main drawback with SILS is the high costs associated with special ports and the special
instruments. Since last 2 years we have been doing modified SILS with one 10 mm standard trocar
and one 5 mm standard trocar with almost invisible scar.
Method: We have performed 55 cases of modified SILS using our technique. One 10 mm port is
placed in lower aspect of the umbilicus at 6 o clock position and gall bladder is assessed for
suitability for SILS and then another 5 mm port is placed at 3 oclock position through a separate
incision.. A minilap grasper (Mini-Lap Technologies) is inserted at the right subcostal region. Rest
of the steps are same as for any standard lap cholecystectomy. Careful and skillful manipulation of
the minilap grasper helps in ant. and posterior dissection of callots triangle, all the while maintaining the triangle of instrumentation (which is not achievable in SILS port techniques). For
clipping the CA & CD we use 5 mm scope thru the 5 mm port and standard clip applicator through
the 10 mm port. Gall bladder is extracted through the 10 mm port. 10 mm port fascia is closed.
Skin is closed with glue or subcuticular stiches. The patient is discharged by evening or next
morning.
Result: 54 cases were completed by the above described modified SILS. One case had to be
converted to standard 4 port technique due to the confusing ductal anatomy. 40 females and 15
males underwent surgery. Mean age was 36 years (range, 1077). There was no mortality. No bile
duct injury or hemorrhage occurred. The median length of hospital stay was 1.1 days (1/2.2 days).
The mean operative time was 45 min (30 to 95 mins). There was no case of any port site hernia. 1
patient developed 10 mm port site infection which responded to dressing and antibiotics.
Conclusion: We have found this modified technique of SILS to be extremely useful in giving the
benefits of SILS to the patient and at the same time keeping the cost to almost same as for any
standard laparoscopic cholecystectomy without compromising the principles of safe surgery.

P548

P550

Real Time Live Transmission Telesurgery Using Novel

Interactive Smartphone and Tablet Technology

Simultaneous Versus Staged Operations for Gastroparesis: Does

Timing of Laparoscopic Feeding Jejunostomy And Gastric
Electrical Stimulator Matter?

Helmuth T Billy, MD1, Jaime Ponce, MD2, 1St. Johns Regional

Medical Center, 2Dalton Surgical Group
Minimally invasive surgery utilizes high definition video cameras to perform complex
procedures. Innovations in smartphone and tablet technology present the opportunity to link
high definition video feeds from operating theaters with one or more remote parties directily
to their smart phone and tablets. Current limitations in telementoring or telesurgery require
expensive video linking systems in order to broadcast live video feeds to limited locations
around the world. These applications are cumbersome and are limited to organized
broadcassting of live surgery transmissions for educational purposes. We present a unique
and novel interactive real time video transmission technology that enables surgeons to
expand live surgery broadcasting in an almost instantaneous format. Telementoring and
telesurgery applications are expanded directly to the smartphone or tablet of individual
physicians and provides the ability for the mentor or collegue to annotate live via a
smartphone or tablet directly to the operating surgeon. Multiple users can be connected as a
student group to watch and discuss remotely during a live surgery directly on their
smartphone via standard WiFi signals in an encripted HIPPA complaint format.
We present successfull utilization of this smartphone application connecting operating
surgeons to collegues at remote sites visualizing and interacting directly with the operating
surgeon using indiviual smartphone via real time audio and video transmission. Continued
technological refinement can allow simple interoperative video communication and consultation between collegues, students and mentors in an almost instantaneous format.
Utlization of smartphone technology as an interactive platform between surgeons can allow
expanded educational training and preceptorship opportunites for surgeons in an inexpensive easy to install format in minimally invasive operating rooms

123

Mena Boules, MD1, Gautam Sharma, MD1, Hideharu Shimizu, MD,

PhD2, Ryan Plescia, PAC1, James Villamere, MD1, Dvir Froylich,
MD1, John Rodriguez, MD1, Matthew Kroh, MD1, Kevin El-Hayek,
MD3, 1Cleveland Clinic, 2Tokyo Metropolitan Tama Medical Center,
3
Cleveland Clinic- Abu Dhabi
Introduction: Gastroparesis is a chronic, debilitating motility disorder for which gastric electrical
stimulation (GES) has shown efficacy. Patients often also require adjunctive nutritional support via
jejunostomy tube (j-tube). Combining these two operations may theoretically increase overall
morbidity, especially in relation to infectious complications. This study aims to assess staged
versus simultaneous procedures for laparoscopic enteral access, and GES placement.
Methods: 185 patients who underwent laparoscopic GES placement at the Cleveland Clinic from
2001 to 2015 were analyzed retrospectively. 124 received GES only never requiring j-tube, and
were excluded from analysis. The remaining 61 patients who had both GES and j-tube placement
were analyzed. Data collected included demographics, nutritional outcomes, j-tube related outcomes, and clinical parameters. Descriptive statistics were computed for all factors. A P value
\0.05 was considered statistically significant.
Results: A total of 61 patients (n = 52, female; n = 9, male) met the inclusion criteria. Mean age
was 39.5 12.0 years, BMI 25.7 7.2, and there was no difference between groups. Mean
albumin prior to any surgical intervention was 4.2 0.5 g/dL. Mean albumin levels 6 months
post-j-tube placement was 4.0 0.6 g/dL. There were no major intra-operative complications or
mortalities reported in any group. 27 had diabetic gastroparesis and 34 idiopathic. Post-surgical
gastroparesis patients do not undergo GES at our institute. According to when patients underwent
j-tube placement patients were divided into 3 groups, group A (n = 13 (21.3 %), j-tube placement
prior to GES), group B (n = 29 (47.5 %), concomitant j-tube and GES placement), and group C
(n = 19 (31 %) j-tube placement post-GES). Rate of wound infection at site of j-tube was 0,
4/29(14 %), and 6/19(31.5 %) in groups A, B, and C. Mean operative duration in group B was
113.0 20.0 minutes. Although not statistically significant, 30-day readmission rates related to
j-tube complications were analyzed, groups B, and C displayed a 31 % and 26.3 % readmission
rate, whereas group A demonstrated 0 % readmission. There were no generator or lead infections in
any group.
Conclusion: The concomitant placement of j-tube during GES implantation is safe and feasible,
with no device related infections or complications. This approach may eliminate the need for a
second. For unclear reasons j-tube complications were higher in groups undergoing combined
procedures and j-tube placement after previous GES.

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P553

Transcystic Duct C-Tube Drainage Ensuring Successful

Postoperative Endoscopic Sphincterotomy (EST) in Patients
with Failure of Preoperative Est: Initial Experience of 12 Cases

Reduced Port Surgery Using an Umbilical Zigzag Incision

in Gastrointestinal Surgery

Ying Fan, Shuodong Wu, Jing Kong, Department of the Second

General Surgery, Shengjing Hospital of China Medical University
Objective: To discuss the value of ensuring successful postoperative endoscopic sphincterotomy
(EST) of transcystic duct C-tube biliary drainage in patients with failure of preoperative EST.
Methods: From Jun 2006 to Oct 2014, 12 cases laparoscopic transcystic duct (C-tube) drainage
were performed in our department. All the patients suffered from chronic calculous cholecystitis.
Patients selection included 9 cases of common bile duct stone and 3 cases of inflammatory stricture
of duodenal papilla with failure of preoperative EST.
Results: Laparoscopic placements of C-tube were successful with no obstruction, no bile leakage
and no biliary hemorrhage. EST were successfully performed with removal of the common bile
duct stones or relief of papilla stricture under the guidance of C-tube postoperatively in all patients.
The postoperative C-tube removal time averaged around 2 weeks and patients experienced no fever
or jaundice.
Conclusions: Laparoscopic transcystic duct C-tube biliary drainage ensures successful postoperative EST in patients with failure of preoperative EST.
Keywords: Endoscopic Sphincterotomy; Biliary Drainage; C-tube

P552
Less Surgery Avoids Body Image Distortion and Improves Patient
Satisfaction With Appearance of Their Abdomen
Sharona B Ross, MD1, Timmothy J Bourdeau1, Jamaal Hardee, MS2,
Darrell J Downs, ATC1, Heather M DeReus1, Whalen Clark, MD1,
Alexander S Rosemurgy, MD1, 1Florida Hospital Tampa, 2University
of South Florida College of Medicine
Introduction: Surgeons aspiring to avoid patient perceived body image distortion are a major
driving force behind Laparo-Endoscopic Single Site (LESS) surgery. This study was undertaken to
determine if patients perceive changes in or distortion of body image after undergoing LESS
surgery.
Methods: At preoperative and first postoperative office visits, patients undergoing LESS surgery
were surveyed about their body image. Patients used a Likert scale to score their perceptions
(1 = definitely disagree to 5 = definitely agree). Patients also ranked their satisfaction with their
overall appearance and their abdominal appearance along a continuous line (0 % very dissatisfied
to 100 % very satisfied). Median data are reported.
Results: 167 patients (age 54 years, 61 % women) were queried. There were no differences before
vs. after LESS surgery for : My body is sexually appealing, I like my looks just the way they
are, Most people would consider me good looking, I like the way I look without my clothes,
I like the way my clothes fit me, I dislike my physique, and I am physically unattractive
(Table 1). As well, postoperatively, satisfaction with overall appearance did not change (Table 1).
Following LESS surgery, patients were significantly more satisfied with the appearance of their
abdomen (59 % preoperatively vs. 82 % postoperatively; p = .04) (Table 1).
Conclusions: Before LESS surgery, patients have a healthy perception of their appearance and
body image. After LESS surgery this does not change; however, there is a surprising improvement
in their satisfaction with the appearance of their abdomen. Body image distortion does not occur
with LESS surgery and, notably, patients denote an improved satisfaction with the appearance of
their abdomen.

Table 1 Greater than preoperative score, p \ 0.04

Yujo Kawashita, MD, Takashi Ueda, MD, Naonori Hazeyama, MD,

Nobuhiro Shin, MD, Fukuoka Seisyukai Hospital
Introduction: Reduced port surgery (RPS) is an increasingly recognized way of conducting
laparoscopic surgery in order to balance the safety and feasibility of single incision laparoscopic
surgery. However, it is still technically demanding procedures and difficult to be standardized
mainly due to its potential conflict of the surgical instruments. To address this issue, a novel
concept of an umbilical Zigzag skin incision was created to hide the scar inside the umbilicus while
securing enough working space. In this study, we retrospectively analyzed our data of RPS through
the umbilical Zigzag incision in patients with gastrointestinal surgery.
Method: A total of 47 patients underwent RPS with this method: 3 partial hepatectomies, 2 distal
pancreatectomies, 7 gastrectomies, 22 colectomies and 13 cholecystectomies. A Zigzag shaped
incision was established right on the umbilicus. Then, a GelPOINT double-ring wound retractor or
Oval-shaped EZ access port was inserted through the incision, as an access port which enlarged the
diameter of the fascial openings to 36 cm. Standard or fine needle laparoscopic instruments were
placed into the abdominal cavity. Once the laparoscope, grasper, and dissector are set, the overall
procedures are similar to the standard laparoscopic surgery.
Results: RPS through an umbilical Zigzag skin incision was successfully completed in all patients
without conversion to open surgery. Additional trocars were inserted as necessary. On average,
operative time was 8.527.8 % longer than that of conventional method. The blood loss, and the
mean postoperative hospital stay were comparable to conventional procedures. Postoperative
complications included 1 seroma, 1 SSI without the need of reoperation. Cosmetic satisfaction was
excellent in almost all cases.
Conclusion: We established a new approach of RPS through an umbilical Zigzag skin incision. We
believe that this approach will widen the application of reduced port surgery in many fields of
surgery by overcoming its technical difficulties, while maintaining favorable cosmetic benefits.

P555
Learning Curve for Single-Incision Laparoscopic Surgery
for Colon Cancer: A Multicenter Observational Study
Suk-Hwan Lee, MD1, Byung Mo Kang, MD2, Bong Hyeon Kye,
MD3, Chang Woo Kim, MD1, Hyung Jin Kim, MD3, Sun Jin Park,
MD4, Kil Yeon Lee, MD4, Sang Chul Lee, MD5, Yoon Suk Lee,
MD6, Sang Woo Lim, MD7, 1Kyung Hee University Hospital
at Gangdong, Kyung Hee University School of Medicine, Seoul,
Korea, 2Chuncheon Sacred Heart Hospital, Hallym University
College of Medicine, Chuncheon, Korea, 3St. Vincents Hospital,
College of Medicine, The Catholic University of Korea, Suwon,
Korea, 4Kyung Hee Medical Center, Kyung Hee University School
of Medicine, Seoul, Korea, 5Daejeon St. Marys Hospital, College
of Medicine, The Catholic University of Korea, Daejeon, Korea,
6
Incheon St. Marys Hospital, College of Medicine, The Catholic
University of Korea, Incheon, Korea, 7Hallym University Medical
Center, Hallym University College of Medicine, Anyang, Korea
Purpose: Single-incision laparoscopic surgery (SILS) was known to be ergonomically uncomfortable and technically difficult for even experienced-surgeons, although it has a better cosmetic
benefit from smaller incision than conventional laparoscopic surgery (CLS). The aim of this study
is to investigate the learning curves for SILS for colorectal cancer of various surgeons from a
multicenter database.
Methods: Data were collected from two different studies. From May 2009 through June 2012,
Korean SIMPLE study group performed a retrospective analysis of SILS for colorectal cancer in
Korea. From August 2012 to now, they have conducted a randomized-controlled, multicenter trial
comparing SILS and CLS. Finally, a total of 406 patients underwent SILS for colorectal cancer by
eleven surgeons from ten institutions. Among them, the data over 20 cases performed by each
surgeon were included. The learning curves were analyzed using the moving average method and
the cumulative sum control chart (CUSUM).
Results: Learning curves for anterior resection by 6 surgeons and right hemicolectomy by 3
surgeons were analyzed. The moving average and CUSUM for anterior resection of indicated that
most experienced-surgeons need to 1436 cases to overcome the learning curve. However, one
surgeon did not show stable operation time during his 42 cases. On the other hand, the learning
curves for right hemicolectomy were ambiguous for two surgeons, whereas one surgeon needed 15
cases to achieve technical stability.
Conclusion: The learning curves of SILS were various in this study. The short-term outcomes were
feasible and stable after 14th36th cases by some surgeons, while the learning curves by others
appeared ambiguous. SILS can be applicable to colorectal cancer for surgeons who experienced
CLS, although it has some uncomfortable characteristics.

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P558

Reduced Port Surgery for Laparoscopic Ventral Hernia Repair

Single Site, Totally Extra-Peritoneal (Tep) Inguinal Hernia

Repair Utilizing a Self-Fixating Mesh

Takeshi Aoki, MD, PhD, T Abe, MD, PhDD, H Imoto, MD, PhD, H
Karasawa, MD, PhD, M Ishida, MD, PhD, K Kudo, MD, PhD, N
Tanaka, MD, PhD, M Nagao, MD, PhD, K Watanabe, MD, PhD, S
Ohnuma, MD, PhD, T Morikawa, MD, PhD, F Motoi, MD, PhD, T
Naitoh, MD, PhD, M Unno, MD, PhD, Department of Surgery,
Tohoku University Graduate School of Medicine
Background: Since 2012, Laparoscopic Ventral Hernia Repair (LVHR) is approved as an insurance adaptation technique in Japan. In our institution, conventional three port LVHR (C-LVHR)
had been performed as a regular surgical option. Ventral Hernia has reduced the patients Quality
of Life, and its repair with the shorter incision and less stress could be beneficial. Recently, we
innovated the Reduced Port LVHR (RP-LVHR), using 3 mm forceps device.
Aim: In this study, we assessed the safety and efficacy of RP-LVHR.
Patients and Method: Patients who underwent the LVHR in our institute during 2004 and 2015 are
included in this study. We compare RP-LVHR and C-LVHR to patients background, operative
time, blood loss and postoperative complications.
RP-LVHR Procedures: We made a small transverse incision about 2 cm at abdominal flank.
Then, we applied a wound protect device (oval type) to the wound. Two 5 mm trocars are inserted
to this device. Creating pneumoperitoneum with carbon dioxide gas, about 10 cm caudal region
from this device, 3 mm port is placed, and 3 mm diameter forceps is inserted from the port. The
intra-abdominal adhesion is dissected and the hernia orifice is observed. Stabbing the thin needle
from the abdominal surface, we confirmed and marked the edge of the hernia orifice. We choose a
PCO mesh enough covering the hernia orifice, and put it into the abdominal cavity from the small
incision. The mesh is lifted the abdominal wall by four non-absorbable surgical sutures. After
lifting the mesh, the mash is fixed to the abdominal wall using the laparoscopic absorbable tacker.
Results: RP-LVHR was performed in 13 cases, and C-LVHR was in 16 cases. Between two
groups, there was no significant difference in termes of operative time (RP-LVHR :
C-LVHR = 119 : 119 min), blood loss (RP-LVHR : C-LVHR = 8 : 15 g). There were no postoperative complications in each group. No recurrence of the hernia was observed in both C-LVHR
and RP-LVHR groups.
Conclusion: RP-LVHR seemed to have the same outcome compared with C-LVHR. In addition,
RP-LVHR is theoretically less invasive and cosmetically beneficial. Therefore, RP-LVHR would
be safe and acceptable procedure for ventral hernia repair.

Alfredo D Guerron, MD, Shaina Eckhouse, MD, Nova Szoka, MD,

Dana Portenier, MD, Jin Yoo, MD, Ranjan Sudan, MD, Keri
Seymour, MD, Chan Park, MD, Department of Surgery, Duke
University Health System
Background: Inguinal hernias are a common problem. 20 million repairs are performed worldwide
every year. Since the 1990s the proportion of laparoscopic repairs has increased markedly. Patient
education and demand for better cosmetic results after surgical procedures have led to an increased
interest in single incision surgery.
Single site laparoscopic surgery has been applied to numerous operations, and has been demonstrated to provide comparable surgical outcomes and with enhanced cosmesis and possibly reduced
post-operative pain. Self-fixating mesh has also been safely applied in laparoscopic TEP procedures, but this mesh has not been described in single site TEP surgery; possibly due to the potential
difficulty with mesh deployment.
This self-fixating mesh delivers tack-free fixation over the entire anatomy, including below the
inguinal ligament where traditional tacks cannot be placed. We sought to determine the technical
feasibility of a single site laparoscopic TEP repair of inguinal hernias and to discuss our techniques
and patient outcomes.
Patient and Methods: We conducted a review of a prospectively maintained database of patients
who received single site laparoscopic TEP herniorrhaphy from August 2012 until present. Patient
characteristics and demographics data, along with perioperative and post-operative data were
analyzed.
Results: 34 patients, ages 55.2 14.1, 82.4 % were males and 17.6 % were females. Mean BMI
26.2 3.8. Mean operative time 99.45 30.5 minutes, 41.2 % were left-sided repairs, 8.8 %
right-sided, and 50 % bilateral. Estimated blood loss (EBL) 18.38 14.1 ml. Primary hernias
were encountered in 85.3 %, and 26.5 % patients received a combination surgerymost common
was concurrent umbilical hernia repair. The most common short-term post-operative complication
was urinary retention (4 patients; 11.7 %), and mean post-operative follow-up was
21.53 9.4 days. One patient presented with persistent swelling, and 3 had inguinal/scrotal pain
that did not require surgical intervention. Long-term complications ([30 days) included hydrocele
(3 patients) and stitch abscess/wound drainage 1 patient. Two patients were followed up to one year
due to pain. No recurrences or mortality were reported.
Conclusions: Single site total extraperitoneal hernia repair is a feasible and safe procedure that
provides excellent cosmesis and may have some benefit with mesh placement and intra-operative
instrument deployment. There were no mortality or recurrences. Urinary retention was the most
common postoperative complication. Hydrocele was the most common [30 day complication.
Chronic pain was only present in 2 patients.

P557

P559

Surgical Treatment Outcomes of Single Port Access

Minilaparoscopic Appendectomy for Appendiceal Mucinous
Neoplasm

Hybrid Ventral Hernia Repair with Acellular Porcine Dermis

Mesh: A Novel Approach

Yoshiyuki Kawakami, PhD, Hidenori Fujii, PhD, Yuki Hirose, PhD,

Japanese Red Cross Fukui Hospital
Aims: We previously reported that trans-umbilical single port access laparoscopic appendectomy
(TUSPA-LA) for complicated acute gangrenous appendicitis could be feasible with some difficult
situation such in cases with intra-abdominal abscess formation. Thus we introduced modified
technique for TUSPA-LA consisted in combining conventional 5 mm trocar with trans-umbilical
single access and newly developed 23 mm mini-laparoscopic instruments with supra-pubic
approach. In this study, we applied this modified technique for appendiceal mucinous neoplasm. It
is expected that our technique could be useful for treating these cases.
Methods: From April of 2011 to July of 2015, 4 consecutive patients with appendiceal mucinous
neoplasm were assigned to undergo surgical treatment with modified TUSPA-LA at our hospital.
We conducted to study our technique using reusable metallic trocar (ENDOTIPTM, 3.3 and 6 mm
in diameter, KARL STORZ GmbH & Co. KG, Tuttlingen, Germany, BJ-NeedleTM trocar, 2.1 mm
in diameter, NITI-ON Co., Chiba, Japan) as working port, XCELTM, 5 mm in diameter, ETHICON ENDO-SURGERY, INC., Pittsburgh, PA, USA, VERSAPORTTM, 5 mm in diameter,
COVIDIEN, INC., Mansfield, MA, USA as camera port. Straight-type grasping forceps and dissecting forceps (2.1, 3.3 and 5 mm in diameter) were used both in the parallel setup at umbilical
site and in the triangular co-axial setup with supra-pubic puncture.
Results: Clinical records of 19 cases of appendiceal neoplasm (From April of 2004 to July of 2015)
were analyzed retrospectively in background factors, operative time and length of hospital stay. Of
them, 13 cases were treated by laparoscopic surgery. We had 4 modified TUSPA-LA (male 3,
female 1, average age of 50.8, range 3764), 3 pure single cases (m 1, f 2, 44.7, 2485) and 6 open
cases (m 4, f 2, 70.6, 5378). The average operative time in the modified group was 62.3 min
(4682), as was 91.9 (42123) in the pure single group, with 94.7 (33140) in the open group. The
median hospital stay in the modified group was 5 (45) days, as was 7 (47) in the pure single
group and 9 (332) in the open group. No major postoperative complications were observed.
Conclusions: We conclude that modified technique for TUSPA-LA could be useful for reducing
invasiveness while keeping a safety and good cosmetic result as an attractive advantage in
managing this condition.

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Valerie Wu Chao Ying, MD, FRCSC, Jose M Martinez, MD, FACS,

University of Miami
Intro: Acellular Porcine dermis (APD) has been increasingly used for challenging ventral hernia
repair. Underlay method can be accomplished via open or laparoscopic techniques but the products thickness has led to challenges using it in a laparoscopic fashion mainly because of
limitations in fixation devices to traverse the thickness of the mesh.
With the introduction of a thinner version of the acellular porcine dermis, we propose the meshs
laparoscopic handling characteristics will allow for easier transfacial fixation and tacking to the
anterior abdominal wall when being placed as an underlay implant in the abdominal cavity.
Methods and Procedures: Retrospective analysis of all patients who underwent laparoscopic
ventral hernia repair using a biological mesh between June 2013 and August 2015 at a tertiary care
center was undertaken. The laparoscopic version was used in 41 consecutive patients requiring
repair of challenging ventral hernias. Cases were performed in a hybrid fashion were hernia sac,
excess soft tissue and facial defects were closed in an open fashion but the mesh was introduced
into the abdominal cavity prior to achieving facial closure to be fixated laparoscopically at a later
point. The mesh was placed in an underlay fashion with minimum of 5 cm underlay in all
directions. Implant fixation including transfacial sutures and tacking to abdominal wall was performed in a laparoscopic fashion.
Results: In all patients, a laparoscopic version of the acellular porcine dermis was fixated in a
laparoscopic fashion. Average mesh size used was 16 9 20 cm. Average defect size was 60 cm2.
No intra-operative complications were encountered. 15 of the 41 patients (36 %) developed wound
events, the majority of which were asymptomatic seromas. One of the patients had a superficial
wound infection treated with local wound care while the other patient was a deeper wound infection
requiring wound debridement. Two patients (5 %) had a hernia recurrence at seven months and one
year respectively.
Conclusion: The introduction of a thinner version of a commonly used acellular porcine dermis has
allowed for the fixation of this implant in a laparoscopic fashion. No significant difference to
traditional thickness (APD) has been seen in this short term follow-up in regards to intraoperative
complication, surgical wound occurrence and hernia recurrence. Longer follow-up studies will be
needed to demonstrate improved or similar results on a long term basis.

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P563

LAPAROSCOPIC TRANSGASTRIC RESECTION

APPROACHES FOR GASTROINTESTINAL STROMAL
TUMORS LOCATED IN GASTROESOPHAGEAL JUNCTION

Final Outcome After Laproscopic Interventional Procedures

in Enteric Perforations with Peritonitis

Nicolasa Fernandez Soria, Alejandra Garcia Novoa, Namibia Sanluis

Verdes, Sergio Builes Ramirez, Maria Jesus Garcia Brao, Pablo
Concheiro Coello, Jose Francisco Noguera, MD, PhD, Hospital
Universitario de A Coruna
Introduction: Gastric submucosal tumors are rare, being gastrointestinal stromal tumor (GIST) the
most common finding. Surgical wedge resection without lymphadenectomy is the first choice of
treatment. Minimally invasive techniques like combined transgastric and endoscopy approach are
useful in tumors located near gastroesophageal junction, avoiding risk of stenosis.
Patients and Methods: We present two cases of GIST located near the gastroesophageal junction
underwent laparoscopic transgastric resection at our institution. The first case was 41-year-old male
evaluated by gastroenterology for dyspepsia founding in upper endoscopy a 2 cm submucosal
lesion located in the gastric fundus, with anatomopathology result of GIST. This was accomplished
using four trocars. The first one was used like usual laparoscopic approach. The other three were
placed intragastric directly through the abdominal wall under laparocospic view. The resection was
made with an endoscopic linear staples.
The second case is about a 3 cm GIST in the gastroesophageal junction diagnosed in a 61-year-old
male. The surgical technique performed was similar to previous case. Due to the proximity of the
tumor to gastroesophageal junction and the incidental gastric perforation due to the use of the
harmonic scalpel this case required endoscopic assistance to the suture.
Results: Postoperative evolution was uneventful, the first patient was discharged on postoperative
day 5 and the other on day 7. The definitive anatomopathologie results confirm the histology
(GIST) and tumor-free margin.
Conclusion: Laparoscopic transgastric resection, with or eithout endoscopic assistance, is possible
and safe, with satisfactory clinicopathologycal results, specially in submucosal tumor located near
to the gastro-esophageal junction.

P562
Reduced Port Surgery for Small Bowel Diseases
Kenji Baba, PhD, Shinichiro Mori, PhD, Yoshiaki Kita, PhD,
Masayuki Yanagi, Kan Tanabe, MD, Takaaki Arigami, PhD, Yuto
Uchikado, PhD, Yoshikazu Uenosono, PhD, Tetsuhiro Nakajyo, PhD,
Kosei Maemura, PhD, Shoji Natsugoe, Prof, Department of Digestive
Surgery, Breast and Thyroid Surgery, Kagoshima University
Objective: Reduced port surgery (RPS) has become an evolving trend over the past few years. We
defined RPS for the patients with small bowel disease as the cases of single port surgery (SPS) or
one additional port to SPS. In this study, we aimed to describe a novel technique and our experience with 10 patients who underwent RPS for small bowel disease.
Methods: This study was designed as a retrospective case series. Between September 2009 and
August 2015, ten consecutive patients who underwent RPS were included (4 male and 6 female,
age: 45.7 24.1 years old). The outcomes were evaluated in terms of operation time, intraoperative blood loss, length of hospital stay after surgery and perioperative complications.
Operation Procedure: We performed double-balloon enteroscopy to mark the lesion with ink,
preoperatively. All patients underwent general anesthesia and were placed in the supine position.
The skin was cut along a Z-line marked in the umbilical region. We used an EZ-access with a LapProtector (Hakko Medical Inc., Chikuma, Japan) for the umbilical access device and an Endo
Relief (Hope Denshi Co., Kamagaya, Japan), which has a 2.4-mm shaft with a 5-mm-diameter head
for additional port. Three 5-mm trocars were placed through the EZ-access for a 5-mm laparoscope
and 5-mm instruments. After setting the EZ-access with the Lap-Protector, pneumoperitoneum was
maintained at 10 mmHg using CO2, and a 3-mm trocar was positioned when needed. An exploration of small bowel was performed under the laparoscopy, the lesion, which had been previously
marked was immediately identified. The specimen was extracted through the incision with wound
protection, after which extracorporeal functional end-to-end anastomosis was performed using
linear staplers. At the end of the procedure, the fascia and the skin at the umbilical incision was
closed using absorbable sutures.
Results: Six patients who had Meckels diverticulum, one patient who had intussusception due to
lipoma, one patient who had polyp with Peutz-Jeghers syndrome, one patient who had small
intestinal stenosis due to Crohns disease and one patient who had small intestinal hemorrhage were
performed RPS, including three patients who added one trocar. Mean of operative time was 110
minutes, and mean of intraoperative blood loss was 10 mL. Length of postoperative hospitalization
was 7 days. There were no complications and mortality in relation to the operation.
Conclusion: Our experience indicates that reduced port surgery for the patients with small bowel
disease is a safe and feasible procedure.

Rajiv Kundu, MD, Jeewan Hospital, Jawalamukhi

Introduction: Typhoid fever is an endemic disease in India & other tropical countries. The
term enteric includes both typhoid & paratyphoid fever and is caused by Salmonella typhi
& Paratyphi A, B&C. Various different types of procedures were advocated by different
authors but still Enteric perforation has a high rate of morbidity & mortality in a open
porocedure as compared to Laproscopic Exploration & repair. Materials & Methods: This
study was conducted at Jeewan hospitals, Jawalamukhi, India between January 2013-January 2015.
Materials and Methods: This Study was conducted for a period of 2 years & the aim of
the study was to compare all different types of approach in Enteric perforation surgery by
Laproscopic intervension in 40 patients. The prospective study group was kept on regular
follow up for the next 6 months & the diversion ileostomy group was called in next
68 months for closure.The various procedures were compared using various statistical
methods like Z test (test of proportion),&t test.
Results: In our Study the age of the patient ranged from 17 to 75 years, M:F ratio was
4.17:1. Fever & abdominal pain was present in all the cases. Leucopenia\4000/cu.mm was
present in majority.abdominal distension. In this study perforation occurred in 1st week of
illness in 57 % of the patients.
Conclusion: Typhoid fever perforation remains a Major health problem in developing
countries & early Laproscopic intervention is the best treatment option by consencus.
Matted bowel loops & gut oedema & inflammation if present, resection & anastomosis
should be avoided & diversion should be considered.

P564
Laparoscopic Complete Mesocolic Excision with Mesofascial
Separation Via Reduced Port Surgery for Colon Cancer
Takako Tanaka, Shinichiro Mori, Yoshiaki Kita, Kenji Baba,
Masayuki Yanagi, Yusuke Tsuruta, Yuko Mataki, Kosei Maemura,
Yasuto Uchikado, Akihiro Nakajo, Shoji Natsugoe, Department
of Digestive Surgery, Breast and Thyroid Surgery, Graduate School
of Medicine, Kagoshima University
We performed laparoscopic complete mesocolic excision (CME) with mesofascial separation via reduced port surgery for the patients with colon cancer. At first we showed
laparoscopic CME for left colon cancer and subsequently showed for right colon cancer.

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P567

Three Ports Laparoscopic Cholecystectomy, Clinical Amiga

Experience - Cali, December 2011December 2014

Mini-Laparoscopy with Interchangeable, Full 5 mm End

Effectors: First Human Use of a New Minimally Invasive
Operating Platform from Two Academic Medical Centers

Claudia Ximena Millan Matta, phd, Monica Torres, phd, Clinical

amiga - colombia
Introduction: Since about 30 years ago described the first laparoscopic cholecystectomy;
modifications have been made to the standard technique. Innovative ways to approach; like
surgery through natural orifices or transumbilical approaches they have been described.
Secure more accepted technique has been under the use of 4 ports; but recently some
working groups have been showing satisfactory results with the use of 3 ports. The
experience of one of these displays.
To describe the results of a retrospective cohort (3 years), a group of patients undergoing
laparoscopic cholecystectomy three ports in Clinical AMIGA - Cali.
Analyze: surgical time, conversion rate, perioperative and late complications, including the
dreaded injury to the bile duct.
Material and Method: a retrospective analysis of 1641 patients undergoing laparoscopic
cholecystectomy using 3 ports, from December 2011 to December 2014 (3100 patients).
Collection of data in a format called REC3PORT; emphasizing epidemiology, conversion
rate to open surgery, surgical time and complications. Later transferred to a digital base for
interpretation.
Results: The average operative time was similar to the series using standard techniques;
conversion rate and perioperative complications are comparable to other series. Hospital
stay and postoperative outcomes were similar to the boarding for 4 ports. IN THIS SERIES
OF CASES NOT FOUND injury Biliary
Conclusion: Laparoscopic cholecystectomy three ports in our series of patients, I evidenced
to be a safe, adequate and reproducible technique in a group trained general surgeons.

P566
Is Laparoscopic Surgery as Effective and Feasible as Open
Resection for Gastric Gastrointestinal Stromal Tumors (GIST)
Lager than 5 cm? Meta-analysis

Mena Boules, MD1, Julietta Chang, MD1, James Villamere, MD1,

Gautam Sharma, MD1, John Rodriguez, MD1, Luigi Boni, MD2,
Matthew Kroh, MD1, 1Cleveland Clinic, 2University of Insubria-Italy
Introduction: The technology of minimally invasive surgery continues to progress in efforts to decrease
postoperative pain and minimize scarring. Needlescopic devices (shaft diameter\3 mm) represent one such
innovation. Widespread use of needlescopic instruments has been hindered by diminished shaft strength and
small or ineffective end-effectors. The PercuvanceTM system uses a 2.9 mm shaft with interchangeable, full
5 mm end-effectors in order to minimize abdominal wall trauma while maintaining the functionality of
traditional laparoscopic instruments. We describe the first human experience of these new instruments at two
academic medical centers.
Methods: Consecutive, unselected patients evaluated for laparoscopic surgery by 3 surgeons at Cleveland
Clinic, and the University of Insubria were included in the study. Patient demographics and operative results
were reviewed. Technical maneuvers using the new instruments are described.
Results: 51 consecutive patients underwent surgical procedures (n = 23 laparoscopic cholecystectomy,
n = 8 colectomies, n = 6 Nissen fundoplications, n = 5 laparoscopic jejunostomy, n = 2 laparoscopic
sleeve gastrectomy (LSG), n = 1 Roux-en-Y gastric bypass (RYGB), n = 1 gastric electric stimulator
placement, n = 1 gastric electric stimulator explant, n = 1 ventro-peritoneal (VP) shunt revision, n = 1
laparoscopic paraesophageal hernia repair, n = 1 laparoscopic duodenojejunostomy, n = 1 laparoscopic
ventral hernia repair (VHR) with mesh) with the use of the PercuvanceTM surgical system. All operations
included Percuvance instruments, ranging from 13 replacement of standard trocars. Percutaneous shafts
were exchanged with different end-effectors throughout the case as needed. One patient was converted to
open surgery due to extensive intra-abdominal adhesions and unclear anatomy. One patient underwent reexploration for presumed anastomotic leak which was found to be negative. Operative time, and length of
hospital stay was similar when compared to standard laparoscopic procedures. There were 3 device malfunctions, which were rectified by instrument exchange. Subjective surgeon experience was overall positive
and functionality of the PercuvanceTM system seemed equal to standard 5 mm laparoscopic instrumentation.
Follow-up as outpatient demonstrated excellent patient satisfaction with scars from Percuvance insertion
sites.
Conclusion: This initial experience with the PercuvanceTM system demonstrated effective exchange of
5 mm port sites for needlescopic instruments with equivalent performance through smaller incisions with
similar handling to traditional laparoscopic instruments, in addition to smaller incision sites. This interchangeable system may allow performance similar to standard laparoscopic port instrument orientation and
principles in the setting of decreased-caliber access.

Jianxin Cui, Aizhen Cai, Hongqing Xi, Kecheng Zhang, Rong Chen,
Bo Wei, Lin Chen, Department of General Surgery, Chinese Peoples
Liberation Army of General Hospital

P568

Background: To determine by meta-analysis, whether laparoscopic surgery is as effective

and feasible as open resection for patients with gastric gastrointestinal stromal tumors
(GIST) lager than 5 cm?
Methods: All records that compared laparoscopic with open surgery for GIST lager than
5 cm published in English from January 1995 to August 2015 were identified in PubMed,
Embase, Web of Science, Google scholar and Cochrane library database. The quality of the
literatures were assessed by NOS scale. Tumor size, operation time, blood loss, postoperative hospital stay, complication rate and disease free survival rate were collected. Metaanalyses were performed using weighted mean differences for continuous variables, odds
ratios for dichotomous variables, and hazard ratios for time-to-event variables.
Results: No eligible randomized controlled trials were identified, but four non-randomized
trials were analyzed, comprising 150 GIST patients with similar tumor size. In the pooled
data of 77 patients who underwent laparoscopic resection and 73 open resection, laparoscopic surgery was associated with shorter postoperative hospital stay (P \ 0.05). However,
there were no significant differences of operation time, blood loss, complication rate and
disease free survival rate between the two groups.
Conclusions: Our findings showed that for patients with comparable tumor size, surgical
technique did not significantly influence the operation factors and oncologic outcomes,
suggesting laparoscopic resection is as acceptable as an open procedure in treatment for
gastric large GIST.
Key words: Laparoscopic; Open resection; Gastrointestinal stromal tumors (GIST); Metaanalysis

Sharona B Ross, MD1, Jamaal Hardee, MS2, Timothy Bourdeau1,

Heather DeReus1, Indraneil Mukherjee, MD1, Christian B Rodriguez,
BS1, Alexander S Rosemurgy, MD1, 1Florida Hospital Tampa,
2
University of South Florida College of Medicine

The Value Patients Assign to Scarless Laparoscopic Surgery

Introduction: Laparo-Endoscopic Single Site (LESS) Surgery represents an evolution in minimally invasive surgery because surgeons forego multiple incisions, hopefully leading to no discernable scar or body
image distortion. This study was undertaken to ascertain the value patients assign to scarless laparoscopic
surgery.
Methods: Before their initial office visit, 604 patients (65 % women; age 58 years; BMI 27 kg/m2) were
surveyed about their body image utilizing a Likert scale (1 = definitely disagree, to 5 = definitely agree)
and were asked to prioritize factors potentially associated with their impending LESS operation.
Results: Patients were neutral about their body image when responding to prompts:

In considering LESS surgery relative to conventional laparoscopy, patients were willing to accept no more
risk (69 %), an operation not longer in duration (52 %), no additional pain (67 %), a recovery not
longer in duration (61 %), no greater risk of incisional hernia (76 %), and no increase in cost (52 %).
In prioritizing possible outcomes achieved with LESS surgery, patients rated (most to least important): risk,
pain, operative duration, and cosmetic outcome (i.e., the lack of a scar) independent of BMI and sex;
younger patients, however, were willing to undergo operations up to 50 % longer if they resulted in no
apparent scar (p \ 0.001). Patients reported that it would not reduce their attraction to LESS surgery if an
additional incision was made on their abdominal wall (86 %) or side (83 %).
Conclusions: Patients are neutral about their body image prior to proposed LESS surgery and generally do
not assign great value to scarless laparoscopic surgery. Several considerations are more important than
cosmesis, particularly for older patients: risk, operative duration, pain, recovery time, risk of incisional
hernia, and cost; cosmesis is more important in younger patients denoting that some patients care very
much about cosmesis. This begs to question: is there too much emphasis on cosmesis? Since traditional
laparoscopy is well tolerated and meeting patients needs, is traditional laparoscopy the end of the road for
all but the younger patients?

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P571

Bidirectional Approach of Video Assisted Neck Surgery (Bavans)

Enables Advanced Endoscopic Lymph Node Dissection
in Thyroid Cancer Surgery: Introduction of a Rigid Endoscope
with Flexible Direction of View

Laparoscopic Gastrectomies for Cancer in the Elderly: Short

and Long Term Outcomes

Akiihro Nakajo, MD, PhD, Hideo Arima, Yoshie Takae, Munetsugu

Hirata, Yoshiaki Shinden, Yuko Kijima, Shoji Natsugoe, Kagoshima
University Hospital
Objectives: We developed a new Bidirectional Approach of Video Assisted Neck Surgery (BAVANS) for
endoscopic thyroid cancer surgery, and have already reported that cranio-caudal approach is extremely
useful for endoscopic complete lymph node dissection (CLND) around the trachea. We consider BAVANS
is better endoscopic technique for CLND than conventional open surgery. In 2014, we upgraded this original
BAVANS via introducing a new rigid endoscope with variable direction of view. Wed like to report a new
version of BAVANS for endoscopic CLND with better maneuverability and cosmetic advantage than
original BAVANS.
Methods: Original BAVANS combines different approaching pathway to the cervical lesion. Prior to lymph
node dissection, we perform endoscopic total or hemi-thyroidectomy via a conventional gasless precordial
or axillary approach. After thyroidectomy, 3 ports (25 mm) inserted at upper neck area to get the craniocaudal view for CLND in original BAVANS. However, this new improved BAVANS requires only 2 ports
(2 and 5 mm) at submandibular area. We could reduce one port on the neck via using a new rigid
laparoscope featuring variable viewing direction.
Results: Total of 42 patients with papillary thyroid cancer received BAVANS and this improved BAVANS
was performed in 24 patients. The average bleeding volume was 25 ml. All patients began oral intake within
5 hours after surgery. Although postoperative Horner syndrome due to injury of the cervical sympathetic
nerve occurred in one patient, no other complications were noted. The average number of retrieved lymph
nodes with unilateral central node dissection was 9, which was same as original BAVANS and was higher
than that achieved with conventional open surgery. All patients were very satisfied with the cosmetic result
of the surgery.
Conclusions: BAVANS is very effective surgical procedure that many endoscopic surgeons can perform
safely and easily. It has both a cosmetic advantage and excellent curability in endoscopic thyroid cancer
surgery. In upgraded BAVANS, we can also get the easy maneuverability and the same quality of CLND as
original BAVANS despite of reducing one port on the neck. Endoscopic thyroid surgery will evolve together
with the new visual technology.

Marta Jimenez Toscano, PHD, Dulce Momblan, MD, Salvadora

Delgado, Jorge Ordonez, Juan Carlos Baanante, Almenara Raul,
Raquel Bravo, Maria Fernandez Hevia, Antonio Lacy, Hospital
Clinic, Barcelona
Background: The longer life expectancy encourages us to perform demanding laparoscopic procedures in fragile group of patient. Nevertheless, the age should not be exclusion
criteria for oncological resection. We evaluate our results in the laparoscopic treatment of
gastric cancer on elderly patients.
Materials and Methods: Retrospective analysis, of a prospective cancer gastric database,
at the Clinic Hospital in Barcelona. The postoperative outcomes as well as possible risk
factors for poor postoperative or long-term results are evaluated.
Results: 67 patients over 75 years old (41, 10 %) were included from June 2006 to May
2015. The mean age was 80 years old (sd 4.01, 7592), with a male/female rate of 1.48/1,
Charlson Comorbidity Index of 6.9 (sd 1.4, 411.2). Most of them were ASA II/III with
advanced gastric cancer. The procedure was achieved with curative intention in 82.1 %,
requiring a total gastrectomy in half of them and a D2 lymphadenectomy in 50.7 % (n:34).
The mean operative time was 257, 9 minutes (210318). The postoperative complications
related with the surgical procedure were 20, 9 % (n: 14). The mortality rate was 4, 5 %
(n:3). Overall survival was 57.56 months (sd 4.8, 48.1166.98). The Charlson Comorbidity
Index and ASA Score had significant relation with postoperative complications but only the
TNM stage was related with worse survival.
Conclusions: The gastric cancer laparoscopic surgeries are feasible and safe in patients
over 75 years old with an acceptable complication rate. The Charlson Comorbidity Index
and the ASA score were the only two factors related with poor postoperative outcomes

P570
Comparison of Costs in Laparoscopic Inguinal Hernia Repairs
Among Surgeons from a Single Institution
Steven Groene, MD, Tanushree Prasad, MA, Amy Lincourt, PhD,
MBA, Brent Matthews, MD, B. Todd Heniford, MD, Vedra
Augenstein, MD, Carolinas Medical Center
Introduction: Laparoscopic inguinal hernia repairs (LIHR) are performed commonly, however, there is no
standardized item utilization in place for the procedure. Our aim was to evaluate and compare cost data
amongst surgeons whom perform this procedure using different surgical approaches and supplies.
Methods: Review of supply utilization cost data, procedure volume and average case length from 9
surgeons within the Carolinas Healthcare System (CHS) from July 2014 to June 2015 was performed.
Descriptive statistics were used to summarize the data.
Results: The average case volume among the 9 surgeons was 14 cases, with minimum 1 case and maxium
37 cases. The average OR time among the surgeons was 110 minutes, with a minimum case length of 101
minutes and maximum 131 minutes. Surgeons E, F and I performed TEP, the others TAP. The average
supply utilization cost of the LIHR was $1100, with costs ranging from $825 to $1381. Trocars represented
53 % of the total supply cost, followed by mesh accounting for 20 %, suture/fixation 9 % and hemostatics
7 %. While all surgeons had their highest percent supply utilization cost in trocars, Surgeon F had the
highest percentage at 71 %(compared to the group average of 53 %). Surgeon E had a higher percent
utilization in suture/fixation compared to the group average (20 % vs 9 %). Surgeon D had a higher percent
utilization in hemostatics than the group average (33 % vs 7 %).
Conclusion: Within CHS, there is a difference in case volume, average case length and cost among 9
surgeons who performed LIHR. The surgeon with the highest average costs had a higher percent utilization
cost for suture/fixation, the surgeon with the second highest costs for trocars, and the surgeon with the third
highest costs for hemostatic agents than the group average.

P572
Laparoscopic Resection of Gastric Gastrointestinal Stromal
Tumors (G-GISTS): A Report of 25 Cases
Chaoyong Shen, MD, Yuan Yin, west china hospital
Objective: To evaluate the clinical value and safety of laparoscopic resection for gastric
gastrointestinal stromal tumors (G-GISTs).
Methods: The clinical data of 25 cases of G-GISTs accepted laparoscopic surgery was
collected from January 2010 to July 2015 in the department of gastrointestinal surgery, west
china hospital. An analysis was performed to evaluate recovery and safety.
Results: The tumors originated from the stomach (n = 25) with diameter \5 cm were
collceted, the location of tumors was pylorus (n = 5), fundus (n = 8), body (n = 12). All
the patients were accepted laparoscopic exploration firstly. 21 cases of gastric GISTs near
greater curvature were successful performed laparoscopic partial gastrectomy, the duration
time were 4570 min, the average blood loss was 15 ml. The other 4 patients were
transferred to open surgery because of the location of the tumor, especially in the lesser
curvature of the stomach. All the patients was able to have liquid food within 4 * 5 d after
operation. The postoperation hospital stay was 7 * 9 d, with no complications after the
operation.
Conclusion: Laparoscopic resection is safe and reliable for G-GISTs patients with diameter
\5 cm, especially located in the greater curvature.

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P575

Laparoscopic Resection of Gastrointestinal Stromal Tumors

(GISTS) on the Posterior Wall of the Stomach

Needlescopic Surgery for Low Rectal Cancer

Zhen-Ling Ji, MD, PhD, Qing-Song Tao, MD, Southeast University

School of Medicine
Laparoscopic surgical techniques are benefits for wedge resection of gastrointestinal stromal tumors (GISTs). We have
developed a new technique of laparoscopic transgastric resection for GISTs of the posterior wall of the stomach by
using a band lifting wedge resection method, which has been confirmed to insure a sufficient surgical margin of the
resected specimen in 32 cases.
GISTs were located at the posterior wall of the stomach were collected in this study. Laparoscopic anterior gastrostomy was made and a 9-Fr rubber band was looped round the tumor bases, thus the tumor was lifting up from the
anterior gastrotomy. The lesion was transacted by a laparoscopic linear cutter and the gastrotomy was closed by
sequential application of the linear cutters. Surgical specimens were examined immunohistochemically.
All GISTs were successfully and completely resected by laparoscopy. The resected tumors shaped ellipse or rotundity.
Macroscopic examination of the resected specimen appeared complete tumor excision with negative surgical margins
in all patients.
A band lifting method for transaction of a GIST on the posterior wall of the stomach can easily obtain enough surgical
margins of GISTs. The technique is reliable and feasible for laparoscopic treatment for GISTs of the stomach.

Jun Nagata, Yosuke Fukunaga, Atsushi Ogura, Shunsuke Hamasaki,

Yukiko Takatsu, Toshiya Nagasaki, Takashi Akiyoshi, Tsuyoshi
Konishi, Yoshiya Fujimoto, Satoshi Nagayama, Masashi Ueno, The
Cancer Institute Hospital of JFCR
Introduction: Laparoscopic colorectal surgery has been shown to result in reduction of postoperative pain and
complications. Needlescopic surgery (NS) is minimally invasive technique that does not reduce the number of ports,
maintaining the same level of quality as conventional laparoscopic surgery. Needlescopic surgery has performed in our
institute since June 2011. In case of abdominoperineal resection (APR) or intersphincteric resection (ISR), the
spiecimen is extracted from perineal incision or anus. Therefore, maximum port size is within 5 mm. It is expected
that Needlescopic surgery for APR/ISR (NS-APR/ISR) reduces the postoperative pain. The aim of this study is to
describe this technique, and to investigate its feasibility for rectal cancer surgery.
Method: From 2011 to 2014, 27 patients underwent NS-APR/ISR in our institution, involving 5 mm and 3 mm ports,
with the exception of the skin hole of colostomy. Mainly 5 mm scope is used through umbilical port. The specimen is
extracted through the perineal incision or anus.
Results: The mean age was 57 (3789). The mean operating time was 290 (215585) minutes, and the mean estimated
blood loss was 50 (3900) mL. There were 3 postoperative complications (more than Grade III of Clavien-Dindo).
There was no conversion to open surgery and no mortality.
Conclusion: NS-APR/ISR for rectal disease is technically and oncologically feasible procedure.

P574
Overcoming The Learning Curve in a Complex Laparoscopic
Procedure (Laparoscopic Donor Nephrectomy)
Virinder K Bansal, Professor1, Devanshu Bansal1, Krishna Asuri1,
Minz m2, Sarabjeet Singh2, Omprakash Prajapati1, Rajeshwari
Subramaniam1, Mahesh C Misra1, 1All India Institute of medical
Sciences, 2PGIMER, chandigarh
Background: LDN is a complex laparoscopic operation which requires advanced laparoscopic skills and dexterity
because of the delicate nature of various structures and the organ which needs to be preserved so that the graft can
perform optimally in the recipient. The vascular structures and ureter need to be handled carefully because of
increased complications if proper harvesting is not done. Such complex procedure entails a significant learning curve
with it. This study was done to estimate our learning curve associated with this complex surgical procedure.
Materials and Methods: This prospective study was undertaken between January 2013 and January 2015. 100
patients were included. A Preceptership - Proctorship model was used to learn this procedure. Senior expert surgeon
from other center was called to mentor the laparoscopic surgeons at our institute. Data recorded included demographic
profile, pre-operative and intra-operative variables, post-operative complications, hospital stay, pain, quality of life and
graft outcome. Learning curve was calculated using the moving average method and calculating the average of
operative time of every five consecutive cases. The learning phase was considered overcome when the moving average
of operative times reached a plateau and when the mean operative time of every five consecutive cases reached a low
point and subsequently did not vary by more than 30 minutes. Statistical analysis was done using STATA and p value
\0.05 was considered significant.
Results: The mean operative time of the procedure was 108.1 26.5 min (range 60180 min) Learning curve of
LDN as measured by the moving average method was achieved at around 20 cases and between 26 and 30 cases
according to the mean operative time of every five consecutive cases. Only few minor intraoperative visceralinjuries
were encountered and all could be managed laparoscopically. Two cases required conversion to open, both being
within the learning curves.
Conclusion: In conclusion, LDN is a complex surgery and has a learning curve associated with it. The best method to
overcome this learning curve even for experienced laparoscopic surgeon is to adopt the perceptorship-proctorship
model of training which as we have shown gives the best results.

P576
Concomitant Total Robotic Paraesophageal And Intrapericardial
Hernia Repair in an Orthotopic Heart Transplant Recipient
Ehsan Benrashid, MD, Linda M Youngwirth, MD, Jacob N Schroder,
MD, Sabino Zani, MD, Department of Surgery, Duke University
Medical Center
Introduction: Intrapericardial hernias (IPH) are a rare entity which frequently result from complications of incidental
or surgical trauma, such as in the setting of a pericardial window or CABG. The most common complaints on
presentation include pain localized to the chest and upper abdomen, with more serious presentations being bowel
obstruction or cardiac tamponade. Although cases of laparoscopic repair have been described in the literature, we
present, to the first of our knowledge, robotic repair of an IPH after orthotopic heart transplantation (OHT), with
concomitant robotic Nissen fundoplication and paraesophageal hernia repair.
Case: The patient is a 60-year-old male with a past medical history significant for ischemic cardiomyopathy resulting
in left ventricular assist device (LVAD) placement complicated by tamponade physiology requiring postoperative
pericardial window. He was bridged via LVAD to OHT approximately 1 year prior to presentation. He was noted to
complain of persistent chest pain, recurrent cough, and reflux type symptoms. He underwent extensive workup
including computed tomography, esophagogastroduodenoscopy, esophageal manometry and barium swallow which
revealed a sliding-type hiatal hernia with a concomitant large IPH containing transverse colon (Figs. 1, 2). Due to his
symptomatology and concern for obstruction, he was taken to the operating room where he underwent successful total
robotic reduction of abdominal contents from the pericardium with primary paraesophageal hernia repair, Nissen
fundoplication, and diaphragmatic repair with 12 cm Parietex mesh (Covidien, Dublin, Ireland) (Fig. 3). He had an
uncomplicated postoperative stay and was discharged on postoperative day 6 on a full liquid diet. On follow up in
clinic approximately 4 weeks later his symptoms of dysphagia and reflux were noted to be resolving (Fig. 2), with
resumption of a normal diet. To our knowledge this is the first report of successful total robotic repair of a paraesophageal and intrapericardial hernia in an OHT patient.

Fig. 1 Preoperative computed tomography demonstrating transverse colon adjacent to heart, without evidence of
obstruction. (A) Axial view of intrapericardial-type diaphragmatic hernia. (B) Coronal view of hernia defect, arrow
demonstrates transition of transverse colon through diaphragm. (C) Sagittal view of hernia defect

Fig. 2 Intraoperative images of robotic IPH. (A) Reduction of omentum and transverse colon through diaphragmatic
hernia. (B) Representative image post reduction of intrabdominal contents from thoracic cavity, heart border seen to
lower left of defect. (C) Following mesh placement for repair of diaphragmatic hernia

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P579

Supply Cost Variability for Robotic-Assisted Prostatectomy

Among Hospitals Within a Single Healthcare System

TAMIS-TME Followed by RPS Technique For Distal Rectal

Cancer

Steven Groene, MD, Davis Heniford, Tanushree Prasad, MA, Amy

Lincourt, PhD, MBA, Vedra Augenstein, MD, Brent Matthews, MD,
Carolinas Medical Center

Junichi Koike, MD, PhD, Kimihiko Funahashi, MD, PhD, Hiroyuki

Shiokawa, MD, Mitsunori Ushigome, MD, PhD, Tomoaki Kaneko,
MD, Akiharu Kurihara, MD, Hironori Kaneko, MD, PhD, Toho
University Medical Center, Omori Hospital, Gastroenterological
Surgery

Introduction: Although robotic-assisted surgery is being utilized more frequently for Urologic,
Gynecologic and General Surgery cases, cost continues to be somewhat prohibitive. Our aim was to
compare supply utilization costs among 5 hospitals where robotic-assisted prostatectomies (RAP)
are commonly performed.
Methods: Review of supply utilization cost data, procedure volume, case length and LOS from 5
hospitals within the Carolinas Healthcare System (CHS) during 2014 was performed. Descriptive
statistics were used to summarize the data.
Results: The average case volume among the 5 hospitals was 41 cases, with a range of 21 to 60
cases. The average OR time was 250 minutes, ranging from 195 to 298 minutes. The average
overall supply utilization cost among the hospitals was $3037; the most expensive hospital
(A) averaged $3762/case and the least expensive hospital (E) $2402/case. Overall and within each
hospital, robotic disposables represented the highest supply utilization cost (44 % of total averaged
costs); hospital A had the lowest percentage attributed this category (31 %). The second-highest
supply utilization cost overall and within each hospital was trays/packs (16 % total averaged costs).
Individually, this amounted to16.2 %, 16.8 %, 11 %, 13.3 % and 26.6 % cost utilization, respectively. Hemostatics represented the third-highest supply utilization cost (9 % total average costs).
Of its total supply costs, hospital A utilized 10 % on electrocautery (vs. 7 % averaged group
utilization), 8 % on clips (vs. 4 %) and 15.4 % on hemostatics (vs. 9 %).
Conclusion: Within CHS, there is a wide variety in case volume, OR time and supply utilization
costs among the 5 hospitals that perform RAP. The hospital that had the highest average itemized
cost generally spent more on electrocautery, clips, and hemostatic agents. Each hospital had the
highest percent utilization cost in robotic disposables followed by kits/trays.

Introduction: TransAnal Minimally Invasive Surgery for total mesorectal excision (TAMISTME)
of distal rectal cancer facilitates dissection of tumors in the deep pelvic floor. TAMIS provides
good visibility and safer transanal TME, while extensive rectal mobilization reduces abdominal
procedures and allows RPS using the wound of ileostoma. We report important anatomical landmarks and surgical outcomes of TAMIS-TME followed by RPS.
Subjects: Surgery was performed in 11 patients (9 men and 2 women, mean age: 67.7 years, mean
BMI: 20.9) from October 2013.
Transanal Procedures: When operating from the anal side under direct vision, after retaining the
space for EZ access followed by insufflation, cephalad dissection of the pelvic floor muscles
follows loose connective tissue outside the pre-hypogastric nerve fascia as a landmark on the
posterior wall. Laterally, dissection proceeds inside the pelvic splanchnic nerves as a landmark.
Although dissection through loose connective tissue outside the splanchnic nerves is possible, care
is required to avoid nerve damage. In males, dissection between the prostate/seminal vesicles and
anterior rectal wall is considered difficult, but magnification facilitates it. Dissection proceeds
cephalad from the rectum along the prostate midline to the pouch of Douglas, followed by right and
left dissection with awareness of the anterior rectal wall. Using the lateral pelvic fascia enclosing
the prostate and rectum as a landmark, transection is done as far from the prostate as possible to
prevent neurovascular bundle injury. Dissection near the prostate reaches Denonvilliers fascia
attached to the rectum.
Abdominal Procedures: With easy anal side connection through the anterior and posterior walls of
the rectum, lateral transection while avoiding neurovascular bundle injury achieves complete
extirpation.
Results: procedures: ISR was 6, CAA 3, APR 2 cases. Operation time was 412 m (ave.), blood loss
was 178.4 ml, postoperative CRP Max was 5.4 mg/dl (ave.)
Summary: When performing TAMIS-TME for distal rectal cancer, magnification achieves not
only safer TME, but also decreasing trasabdominal procedures while allowing RPS. However,
proficiency in recognizing anatomical landmarks from the anal side is essential.

P580
P578
Virtual Translumenal Endoscopic Surgical Trainer (VTESTTM):
An Evaluation Study
Jinling Wang, PhD1, Woojin Ahn, PhD2, Denis Dorozhkin, PhD2,
Daniel B Jones, MD, MS, FACS3, Suvranu De, ScD2, Caroline G.L.
Cao, PhD1, 1Wright State University, 2Rensselaer Polytechnic
Institute, 3Beth Israel Deaconess Medical Center, Harvard Medical
School
Introduction: Natural Orifice Translumenal Endoscopic Surgery (NOTES), as a new procedure,
needs effective training methods. A virtual translumenal endoscopic surgical trainer (VTESTTM) is
being developed for the training of the hybrid rigid transvaginal NOTES cholecystectomy procedure. It is the first virtual NOTES simulator. After modifications based on the feedback collected at
the 2013 and 2014 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
Summit, the new and improved simulator was evaluated at the 2015 NOSCAR summit.
Methods and Procedures: Ten participants were recruited at the 2015 NOSCAR Summit. There
were 9 males and 1 female with an average age of 42.7 (SD = 6.1). Three of them had performed
NOTES. The participants were asked to complete a questionnaire about their surgical experience.
After being shown a demo video of the simulator and a hybrid transvaginal NOTES cholecystectomy procedure, the participants were asked to perform the task on the simulator and then fill out
a questionnaire to provide their feedback.
Results: There were 18 subjective preference questions. Subjects rated their preference using a
5-point Likert scale (ranging from 1: not realistic/not useful/not trustworthy/disagree; to 5: realistic/
useful/trustworthy/agree). Participants gave a median score of C 3 for 13 questions, including those
related to the realism of anatomy/Calots triangle/simulator interface/rigid endoscope navigation/gall
bladder removal task, usefulness in learning hand-eye coordination/ambidexterity skills/fundamental
NOTES technical skills, trustworthy in quantifying accurate measures of performance/providing
different hand-eye coordination, realism of the simulator as a trainer, and usefulness of the simulator
for training before operating room experience and certification. A median score of\3 was noted for
only 5 questions which were related to the realism of the instrument handling and the blunt dissection
task/overall realism/quality of force feedback/and usefulness of force feedback. These results were
consistent with the responses to the open-ended questions.
Conclusion: Expert feedback results show that the simulator is deemed to be useful and trustworthy, but further improvement is needed especially for the quality of force feedback in the
simulator.

Per Oral Endoscopic Myotomy: Outcomes and Lessons Learned

from Starting A New Poem Program at an Academic Institution
Albert Huang, MD, Vid Fikfak, MD, Carter Smith, MD, Nabil Tariq,
Vadim Sherman, Lee Morris, Patrick Reardon, Brian Dunkin, MD,
Houston Methodist
Background: POEM is a relatively new treatment for achalasia first reported by Inoue in 2010.
POEM was first performed in the state of Texas at the Houston Methodist Hospital in 2013. This
study presents the results of that work including the process of introducing a novel endoscopic
procedure into the operating room and the outcomes of POEM procedures performed at our
institution.
Methods: In preparation for starting a new POEM program, the principle investigator observed
cases performed by Professor Inoue in Yokohama, Japan. Professor Inoue then visited the PIs
home institution as guest faculty and proctored POEM cases done by the PI in an animate lab.
Following this experience, the PI rehearsed the procedure on porcine explants until able to reliably
complete it without inadvertent mucosotomy. In conjunction with this technical rehearsal, a POEM
operating room team was assembled, specialized equipment carts created, institution review board
approval gained to monitor and report on patient outcomes, and a hospital credentialing pathway
defined. Patients were then sequentially enrolled and an expert proctor was present for the first two
clinical cases.
Results: Between September 2013 and October 2015, 42 POEM procedures were completed. Mean
operative times (minutes) were 148 35 total, mucosotomy 6 7, tunnel 69 31, and myotomy
34 21 with no decrease in time over the series. Blood loss was B 3 ml on all cases and there
were no mucosal perforations. Pneumoperitoneum occurred in 17 (4 %) cases requiring Veress
needle decompression in 15 (36 %). Postoperatively, the median length of stay was one day, most
patients required no narcotics, and there were no leaks or delayed bleeding episodes. One patient
underwent a negative CT scan for acute chest pain on post-operative day one. There were three
treatment failures: One in a patient with an uncategorized esophageal motility disorder where
POEM was used as a final therapy before esophagectomy, and two with incomplete myotomy,
rescued with pneumatic dilation. The mean dysphagia health index (DHI) decreased significantly
(60.3 preop vs 22.5 postop; p \ 0.01) while heartburn quality of life scores did not change significantly (4.4 preop vs 6.5 post op).
Conclusion: This study presents a method for introducing POEM safely into the operating room
while shortening the clinical learning curve. Quality of life survey results show efficacy with no
serious complications. We hope this initial experience will serve as a guide for other programs
introducing this procedure into their institution.

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P583

Needs Analysis for Developing a Virtual Reality Simulator

for Notes

Transanal Laparoscopic Repair of Rectal Anastomotic Leak

Using Single Port Device Innovated and Safe Approach

Woojin Ahn, PhD1, Denis Dorozhkin, PhD1, Steven Schwaitzberg,

MD2, Daniel Jones, MD3, Suvranu De, ScD1, 1Rensselaer Polytechnic
Institute, 2University at Buffalo School of Medicine and Biomedical
Sciences, Harvard Medical School, 3Beth Israel Deaconess Medical
Center, Harvard Medical School

Mohammed K Al Sibani, MDFRCSC1, Kin F Chin, MD, FRCS2, POk

E Hong2, 1Armed Forces Hospital, 2University of Malaya

Introduction: A virtual translumenal endoscopic surgical trainer (VTESTTM) is being developed to

provide a safe and risk-free platform that enables developing and training new procedures and
designing and testing new instruments for natural orifice translumenal endoscopic surgery
(NOTES). As new NOTES procedures are being developed in diverse surgical fields, emerging
trends and needs must be continually investigated to ensure clinical relevance of the virtual reality
simulator. This paper reports a questionnaire survey that follows previously conducted similar
studies in 2011 (Sankaranarayanan et al. in Surg Endosc 27:16071616, 2013) and 2012 (Schwaitzberg et al. in Surg Endosc online 2015)
Methods: A 32-point questionnaire was distributed at the 2015 annual Natural Orifice Surgery
Consortium for Assessment and Research (NOSCAR) meeting. The obtained responses from
experts were analyzed using one and two sample t-test for comparison of two proportions.
Results: Thirteen NOTES experts participated in the 2015 study. In similar to 2012, cholecystectomy (CE) has remained the most commonly performed NOTES procedure, with eight (62 %)
responses (2012 vs 2015, p = 0.85), followed by peroral endoscopic myotomy (POEM) with five
(38 %) responses (2012 vs 2015, p-value = 0.95). Interestingly, in contrast to 2011 and 2012,
POEM is reported as the single best indication for NOTES to eventually become standard of care
with five (38 %) instances while only one (7 %) participant indicated cholecystectomy (POEM vs
CE, p-value = 0.08). The trends remains consistent since POEM was identified as a promising
candidate for future simulator development in the 2012 study (2012 vs 2015, p-value = 0.85). The
popularity of the NOTES appendectomy remained relatively lower (15 %) compared to cholecystectmy (p-value = 0.03) and POEM (p-value = 0.25). Other NOTES procedures preformed
recently include tubal ligation, colectomy, transgastic peritoneoscopy, pancreatic necrosectomy,
fundoplication, specimen extraction, pancreatic pseudocyst gastrostomy, and GIST removal. The
importance of virtual reality NOTES simulators for training and developing in new procedures has
been scored highly with a mean score of 4.04, 4.15 and 4.07 for the five-point Likert scale questions
in 2011, 2012, and 2015, respectively. The participants rated the importance of VR-NOTES
simulator for POEM training with a mean score of 3.83.
Conclusion: The results indicate that POEM should be the next virtual NOTES simulator to be
developed. These preliminary survey data will be subsequently augmented by an identical online
survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the
Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed to obtain more
statistically meaningful results.

P582
Notes Transvaginal Surgery: Dead or Alive in 2015? Results
of a Survey
Alberto Raul Ferreres, MD, PhD, FACS, hon, Rosana Trapani, MD,
Pablo Miguel, MD, Julieta Camelione, MD, Leandro Cardozo, MD,
Paula Curvale, MD, University of Buenos Aires
Introduction: Laparoscopic cholecystectomy (LC) introduced in the late 80s is currently the
standard of care for the treatment of cholelithiasis. New approaches such as NOTES and SILS
developed but did not catch the attraction of surgeons and patients. TV NOTES cholecystectomy
appears in the surgical armamentarium around 2007 but recent adoption rates are very low,
exception made of Germany. Our objective was to assess surgeons opinion regarding this approach
and its validity.
Methods and Procedures: Between march and august 2015, this study surveyed 240 surgeons
trained in TV cholecystectomy in our hands- on courses set up between 2008 and 2013 using an end
point questionnaire designed to establish their opinion with respect to NOTES surgery in comparison to standard laparoscopic cholecystectomy. The statistical analysis was performed with the
Mann Whitney U test, and a p-value of B was considered to be statistically significant.
Results: The surveys were completed by 180 surgeons (75 %), 157 (87 %) were from Argentina,
20 (11 %) from Latin American countries and 3 (2 %) from the rest of the world (2 Europe, 1
Africa). 170 were males (94 %) and the average age was 43.4 years (ranges 3253). The number of
courses was: 6 in 2008 and 6 in 2009; 4 in 2010 and 4 in 2011, 2 in 2012 and 1 in 2013. Each course
hosted 10 participants each, with a required experience of more than 3 years or 130 cases of
previous LC.
None of the surgeons with the exception of 2 (1 %) are still performing NOTES TV cholecystectomy. These 2 surgeons performed less than 10 cases yearly and only under patients request.
None of the 10 female surgeons would accept a TV performed on them. It was unanimous the
opinion that NOTES TV cholecystectomy is not a valid alternative and 153 (85 %) believe NOTES
represents an unncessesary innovation, while the remaining 15 % considered there is a place, both
for transoral and transanal procedures. Reasons for abandonment of this technique are multiple.
Conclusions: After an initial upheaval with partial embracement, the situation regarding NOTES in
2015 seems to have changed. A significant skepticism is the rule in surgeons trained in this
procedure. Standard laparoscopic cholecystectomy stills remains the accepted standard of care for
the treatment of symptomatic gallbladder stones and NOTES remains to be an alternative to the
access of both ends of the digestive tract.

123

Background: Anastomotic leak after anterior resection is a common complication which arises in up to
20 % of cases. Preoperative general condition of the patient, level of the anastomosis and duration of
operation are considered important contributory factors. Transanal endoscopic microsurgery (TEMS) has
emerged as a safe and effective method to treat many early rectal lesions.
Objective: In this article we describe a minimally invasive approach in three patients with early rectal
anastomotic leak after low anterior resection LAR for rectal cancer. With this technique it was possible to
visualize and repair the defect without the need for defunctioning colostomy after controlling the contamination and allowing the inflammation to subside.
Cases History: Three patients underwent LAR for rectal cancer sustained early anastomotic leak were
managed initially with percutaneous drain, intravenous antibiotics and defuntioning ileostomy for 2 weeks
and then they were taken for transanl laparoscopic repair.
Intervention: Single port device and conventional laparoscopic instruments were used to repair the anastomotic defect. The defect was repaired using intra corporeal interrupted absorbable suturing. Ful thickness
of the rectal wall was approximated. The defect was well approximated and there was no residual gaping.
Result: Post-operative course was uneventful and gastrographin enema showed no evidence of anastomotic
leak. All patient return back to normal activity within two weeks. No long term complication after 2 years of
follow up .
Limitation: The technique is demanding due to narrow working field and instrument crowding. laparoscopic suturing of distensible colon was a major challenging .
Conclusion: Transanal minimally invasive surgery is an excellent approach to treat anastomotic leak after
LAR for rectal cancer in selected patients. It provides an alternate to major pelvic surgery, which carries the
risk of intra-operative and postoperative complication. In addition, it obviates the need for colostomy and a
second intervention. Surgeon experience as well as carful patient selection is required before embarking in
such task. The learning curve is steep because the number of cases are rather small for surgeons to acquire
technical expertise.

P584
Short-Term Results of Down-to-Up TME by Tamis Following
Trans-Anal Intersphincteric Dissection for Very Low Rectal
Cancer
Masaaki Ito, Yuji Nishizawa, Takeshi Sasaki, Akihiro Kobayashi,
National Cancer Center Hospital East
Objective: The aim of this study was to clarify the short-term results and surgical tips of down-to-up TME
by TAMIS following trans-anal intersphincteric dissection (ISD + TAMIS-TME) for very low rectal cancer
near the anus.
Methods: We experienced this procedure in thirty-one C-Stage lower rectal cancers locating within 5 cm
from the anal verge. In the first step of this procedure, transanal intersphincteric dissection was performed
from 2 cm distal side of the tumor till the level that the puborectal muscle was fully exposed and then placed
Gelpoint path in the anal canal. Distal stump was closed to prevent cancer cell dissemination and irrigate the
anal canal. Down-to-up TME was performed under pneumoperitoneum using conventional laparoscopic
devices till the level of the peritoneal reflux. Next, we moved to the abdominal side and did conventional
laparoscopic procedures to make resection of the specimen. Reconstruction was made by hand-sewn coloanal anastomosis. Diverting ileostomy was created in all the patients.
Results: Of 31 patients, laparoscopic pelvic side-wall dissection was performed in 20 cases. Median total
operative time and median blood loss was 251 min and 75 ml in patients without pelvic side-wall dissection
and 352 min and 81 ml in patients with one. Median operating time in the part of TAMIS was 76 min in all
the cases. No complications were found in TAMIS related procedures. Conversion was found in one. We
had grade III postoperative leakages in 3 patients and grade IV in 1 patient. R0 operation was achieved in all
patients. Urinary dysfunction with residual urine of [100 ml at 5 POD was found in 5 patients, who would
all recover in one month. As the greatest merit of this procedure, we could get the clear exposure at the
anterior side of the rectum which could not be seen in conventional laparoscopic TME. We could identify
the recto-urethral muscle here and we could get to the prostate clearly after cutting the structure.
Denonvilliers fascia could also be seen as next important structure. The seminal vesicle was exposed after
cutting this fascia, and we could reach to the peritoneal reflux under TAMIS.
Conclusion: Down-to-up TME by TAMIS following trans-anal intersphincteric dissection could offer
feasible procedures in any lower rectal cancer patients with the various morphology of the pelvis. We should
learn specific surgical anatomies in performing TAMIS.

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S477

P585
Treatment of Achalasia with Peroral Endoscopic Myotomy
(POEM): Analysis Of 42 Consecutive Patients
Erica D Kane, MD, MPH1, Mersadies Martin, MD1, Amy BanksVenegoni, MD2, David B Earle, MD1, David J Desilets, MD, PhD1,
John R Romanelli, MD1, 1Baystate Medical Center, 2Spectrum Health
Medical Group, Grand Rapids, MI
Introduction: Per oral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia
based on encouraging short-term outcomes in multiple series worldwide.
Methods and Procedures: Data were collected prospectively on all patients undergoing POEM at a single institution
from June 2011 through September 2015. Preoperative diagnosis was confirmed by high-resolution manometry,
barium swallow, and endoscopy.
Results: Forty-two POEM patients were included, 40 diagnosed with achalasia (types I-III), 1 with nutcracker
esophagus, and 1 diagnosed intraoperatively with scleroderma. The mean age was 55.8 +/- 17.0 years. Mean BMI was
29.3 +/- 8.7. Preoperative mean Eckardt score was 7.5 +/- 2.7 (range 112), with mean dysphagia component 2.6.
Thirty-six patients presented with dysphagia, 24 with regurgitation, 18 with chest pain, 14 with weight loss, and 1 with
aerophagia. Of the 42, 6 (14.3 %) patients had intramuscular botulinum toxin injection pre-operatively, and 19
(45.3 %) had previous dilations. Median OR time was 145 minutes (range 70462) and median length of stay was
1 day (range 0.88). Average myotomy length was 12.9 +/- 2.5 cm. Average number of clips for mucosal closure was
4.5 +/- 2.3. Of 20 full-thickness dissections noted through muscular layers, 12 patients developed intra-operative
pneumoperitoneum, 8 were decompressed by Veress needle, and none suffered further sequelae. One early case was
converted to a laparoscopic Heller myotomy (due to Botox injection ten days preoperatively) and two cases were
aborted; one due to extensive submucosal fibrosis and the other to intra-operative capnopericardium. There were no
deaths. Two intra-operative complications occurred: one major - cardiac arrest due to capnopericardium; the other
minor - a mucosal injury at the gastroesophageal junction successfully repaired with clips. The patient whom experienced capnopericardium was the only patient with post-operative complications - intubation for respiratory distress
and development of atrial fibrillation. Mean post-operative Eckardt score was 1 +/- 1.7 (range 08) at 26 weeks
(p \ 0.0001, compared with pre-operative score), with mean dysphagia component 0.3 (p \ 0.0001, compared to preoperative score). Two recurrences were identified, both at 6 months.
Conclusions: POEM is a safe and durable treatment for achalasia, although longer-term data will be helpful. We
demonstrated a marked improvement of symptoms in all completed cases evidenced by significant improvement in
Eckardt score. There was an acceptable serious adverse event rate of 2.4 % in this series and recurrences occurring in
only 4.7 % of cases in the short term.

Fig. 1 .

P586
Severe Hydronephrosis and Perinephric Urinoma with Rupture
Of Renal Fornix Secondary to Post-Operative Urinary Retention
Following Laparoscopic Umbilical Hernia Repair: A Case Report

Fig. 2 .

Anthony Dakwar, MD, James Wysock, MD, James Satterfield, MD,

New York-Presbyterian/Queens
Introduction: A case of delayed post-operative urinary retention (POUR) in a female resulting in severe unilateral
hydronephrosis with perinephric urinoma due to a ruptured fornix.
Case Report: A forty-three year old female without significant medical history and normal pre-operative imaging
underwent an uncomplicated, laparoscopic umbilical hernia repair. A 16-French (Fr) Foley catheter was placed
preoperatively without difficulty and removed on post-operative day (POD) one with spontaneous voiding.
On POD two, the patient developed an intestinal ileus and reported inadequate pain control requiring hospital
admission which had resolved conservatively. On POD four, the patient complained of dysuria, urinary hesitancy, and
right flank pain. Vitals at the time: heart rate of 93 bpm, BP of 138/86 mmHg, respiratory rate of 22, and temperature
of 38.2 degrees Celsius. Physical exam elicited a soft, but distended abdomen with right CVA tenderness. Significant
laboratory values included an acute WBC to 17,000 and creatinine rise from 0.7 to 5.5 mg/dL. The patient was
catheterized with a post-void residual of 800 cc.
A CT of abdomen/pelvis without contrast showed severe right-sided hydronephrosis, a perinephric fluid collection, and
dilated right ureter down to the level of the bladder. The patient underwent cystoscopy and retrograde pyelogram
which demonstrated severe hydroureteronephrosis and a severely tortuous ureter (Fig. 1). Attempts to catheterize the
right renal collecting system were unsuccessful secondary to proximal ureteral tortuosity. Afterwards, a percutaneous
nephrogram was performed where a stiff guidewire was successfully passed into the bladder by interventional radiology (IR) and allowed for placement of an indwelling 8-Fr double-J ureteral stent (Figs. 2, 3). At the end of the
procedure a diversionary 8-Fr nephrostomy catheter was placed into the renal pelvis.
On post-procedure day one, the patients WBC and serum creatinine had normalized. Thereafter, the patient was
discharged with a bladder catheter and the indwelling stent. The patient has since resumed normal voiding and both her
ureteral stent and percutaneous nephrostomy have been removed.
Discussion: This case describes an axial rotation of hydroureter and ruptured right renal fornix with perinephric
urinoma secondary to delayed POUR, an unusual occurrence. The treatment that was employed was not only therapeutic but also diagnostic in nature, concluding that CT should be part of the initial steps of diagnosis as it can
illustrate defects within the renal pelvis, ureter, and retroperitoneal space. Thereafter, cystoscopy or IR may need to
play a role in the absolute treatment of a ruptured fornix.

Fig. 3 .

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P587

P589

Laparoscopic Versus Open Surgery in Patients with Psychiatric

Comorbidity: A Retrospective Study at the Largest Psychiatric
Center in Japan

Intracorporeal Triangular Anastomotic Technique for Billroth I

Reconstruction After Laparoscopic Distal Gastrectomy

Baongoc Nasri, MD , Masanori Tada, PhD, MD , Ken Yuu, MD ,

Marius Calin, MD2, 1Tokyo Metropolitan Matsuzawa Hospital, 2Saint
Vincent Hospital Indianapolis
Objectives: To compare the outcomes of laparoscopic versus open surgery in patients with psychiatric comorbidity.
Background: Several studies have linked the presence of psychiatric disorders to increased risks of distinct diseases
and suboptimal outcomes. Although laparoscopic approach is minimally invasive, it is unclear whether laparoscopic
surgery is safe for patients with psychiatric comorbidity.
Method: A retrospective chart review of surgical patients with psychiatric comorbidity at a metropolitan hospital in
Japan from August 2013 to August 2015 was done. Patients were divided into laparoscopic group (LG) (n = 55) and
open group (OG) (n = 72). The groups were compared by operating time, estimated blood loss, day starting oral
intake, length of stay, complication and mortality. Logistic regression analysis was performed to delineate the predictors of complication and mortality. Ordinary least squares regression analysis was performed to delineate the
predictors of operating time. Independent variables are age, BMI, ASA, diagnosis of malignant/benign. Statistical
analysis was performed using R programming version 0.98.490. A p value of 0.05 was used as statistically significant.
Results: The sample included 68 (63 %) patients with schizophrenia, 22 (21 %) with dementia, 37 (14 %) with others.
There were 15 (11.8 %) gastrectomies and 34 (26.7 %) colorectal resections for malignant diseases. The perioperative
data set including the female to male ratio, age, BMI, ASA, the rate of malignant disease showed no difference in the
two groups. The conversion rate was 1.8 %. The operating time was higher in LG compared to OG (mean [SD], LG
176 [80.6] min vs OG 72 [123] min; (p \ 0.05). The estimated blood loss was lower in LG compared to OG (mean
[SD], LG 101 [222.9] ml vs OG 173 [233.2] ml; (p \ 0.05). There was no difference in the length of stay, day starting
oral intake, complication and mortality between LG and OG. After adjusting for age, BMI, ASA, diagnosis of
malignant/benign, LG was associated with a decreased odds ratio for complication and mortality. Multiple linear
regressions showed increased operating time in LG compared with OG.
Conclusions: Even though laparoscopic surgery had longer operating time, there was no difference in the length of
stay, complication and mortality between laparoscopic and open surgery in patients with psychiatric comorbidity.
After further study of patient selection criteria, we hypothesize that laparoscopic procedure is a preferred option for the
increasing population with underlying psychiatric diseases.

Hirotaka Sasada, PhD1, Fumihiro Wakayama1, Takehiro Sakai1,

Kohji Nagao1, Tadashi Iwabuchi1, Nobuo Yagihashi1, Shunnichi
Takaya1, Juno Nagayama2, Tsuyoshi Murakami3, 1Tsugaru General
Hospita., 2Tokiwakai Hospital, 3Hirosaki University
Introduction: Before we performed hemi double stapling technique (DST) after laparoscopic distal gastrectomy
(LDG). The method needs about 5 cm laparotomy on epigastrium. Now for complete laparoscopic surgery we
performe intracorporeal triangular Billroth I (B-I) anastomotic technique after laparoscopic distal gastrectomy (LDG)
for gastric cancer as Dr. Takeshi Omoris method. We report the result.
Methods: After LDG, we make a small incision to remnant stomach and duodenum. We perform anastomosis with
linear stapler, close the common hole with linear stapler, and remove the stump of duodenum with linear stapler. Then
the anastomosis is completed.
Results: Between January 2014 and Aug 2015, the number of LDG was 32 patients. Among 32 examples B-I
anastomosis was 10, Billroth II (B-II) anastomosis was 9, and Roux-Y anastomosis was 13. 9patients were performed
intracorporeal triangular anastomotic technique (INTACT) among 10 B-I patients. Gastric cancer of patients performed INTACT were early stage of gastric cancer. Every operations were performed through 5 access ports. Mean
operation time was 271 58 minutes, mean bloodloss was 20.0 40.0 mL. Mean postoperative hospital day was
13.1 10.3 days in 8 patients performed INTACT except 1 patient of delayed gastric emptying. Postoperative
complication was 1 delayed gastric emptying and 1 lymphorrhea. These 9 patients performed INTACT are compared
with nearest 10 patient performed hemi double stapling technique (DST) previous. In 10 patient performed hemi DST
mean operation time was 290.0 39.4 minutes, mean bloodloss was 76.9 75.5 mL. Mean postoperative day was
16.7 18.6 days. Tere is no significant difference between patients performed INTACT and patients performed hemi
DST.
Conclusions: Intracorporeal triangular Billroth I anastomotic technique is useful as B-I reconstruction after lanaroscopic distal gastrectomy.

P590
P588

Novel Prognostic Factor in the Colorectal Cancer Patients Who

Underwent Laparoscopic Surgery

Utilizing Activity Trackers as a Novel Strategy to Increase

Postoperative Ambulation and Evaluate the Impact of Mobility
on Bariatric Surgery Outcomes

Toshihiro Nakao, Mitsuo Shimada, Kozo Yoshikawa, Jun

Higashijima, Takuya Tokunaga, Masaaki Nishi, Chie Takasu, Hideya
Kashihara, Department of Surgery, The University of Tokushima

Ryan Macht, MD1, Amy Holmstrom, BA2, Kathryn Van Orden, MD1,
Kevin Wong, BA2, Anthony Khalifeh, BA2, Brian Carmine, MD,
FACS1, David McAneny, MD, FACS1, Donald Hess, MD, FACS1,
1
Boston Medical Center, 2Boston University School of Medicine

Background: Recently, much attention has been paid to the sarcopenia, Glasgow prognostic score (GPS) and neutrophil-to-lymphocyte ratio (NLR) to predict the prognosis of several cancers. The aim of the present study was to
assess the efficacy of sarcopenia, GPS and NLR as the prognostic factors in the colorectal cancer patient who
underwent laparoscopic surgery and establish the new prognosis score.
Patients and Methods: Seventy-six colorectal cancer patients who underwent radical laparoscopic surgery between
January 2004 and April 2009 were analyzed. Cross-sectional areas (cm2) of skeletal muscle were measured at the third
lumbar vertebra by computed tomography. The presence of sarcopenia was defined as skeletal muscle area under 75 %
of the standard area of skeletal muscle at the third lumbar vertebra. Preoperative NLR was calculated. The cut-off
value of NLR was defined as 3.2 by median value. The GPS was calculated based on cut-off values of 1.0 mg/dl for
CRP and 3.5 g/dl for Alb, as previously reported. The new predictive score, sarcoGPS, was calculated based on CRP
and the presence of sarcorenia instead of Alb. The cancer-specific survival (CSS), disease-free survival (DFS),
postoperative complication rate and postoperative hospital stay were evaluated.
Results: There was no significant difference of CSS in GPS, NLR (p = 0.48, 0.27). The CSS in sarcopenia patients
was significant worse than non-sarcopenia patients (p [ 0.05). The CSS in patients with sarcoGPS 2 tended to be
worse than sarcoGPS 0 and 1 (p = 0.07). There was no significant difference of DFS, postoperative complication rate
and postoperative hospital stay in sarcopenia, NLR, GPS and sarcoGPS.
Conclusion: The sarcopenia and sarcoGPS may be the prognostic factors in the colorectal cancer patients who
underwent laparoscopic surgery.

Introduction: Early postoperative mobilization is the standard of care for bariatric surgery. However, it is often
challenging to motivate patients to walk following an operation. In addition, the inability to easily and accurately
measure ambulation has made it difficult to evaluate the association between mobility and postoperative outcomes.
Activity trackers have emerged commercially as an incentive for exercise, but they have rarely been utilized in the
postoperative setting. The aims of this study are to evaluate activity trackers as a postoperative motivational tool and to
assess the association between ambulation and bariatric surgery outcomes.
Methods: We performed a randomized trial at Boston Medical Center of all patients undergoing a primary bariatric
operation. Patients were provided a Modus StepWatch activity tracker to wear immediately after their operation and
until their two-week follow-up appointment. Patients underwent 1:1 randomization into two groups, with one group
receiving no feedback on their step quantity and the other group receiving twice-daily ambulation feedback in the
inpatient setting only. A brief survey was given to participants following the two-week study period.
Results: Of 108 randomized patients, 87 had complete inpatient data, and 62 had both complete inpatient and
outpatient data. No baseline differences in age, BMI, gender, or surgery type between the no-feedback and feedback
groups were statistically significant (Table 1). No significant difference between groups was seen for inpatient
steps/day (3,308 vs. 3,353, p = 0.88) or outpatient steps/day (5,548 vs. 5,842, p = 0.59). When the two groups were
combined, there was no significant association between steps/day and 6-week weight loss, hospital length of stay, or
venous thromboembolism. However, those with a 30-day unplanned Emergency Department visit or hospital readmission had fewer initial inpatient steps/day (2,682 vs. 3,446, p = 0.06) than those with no unplanned visit. Survey
results demonstrated that 81 % of patients agreed that wearing the activity tracker motivated them to walk more than if
they were not wearing it.
Conclusion: The use of activity trackers in the postoperative setting is a promising intervention to motivate ambulation. Although, providing inpatient feedback did not significantly increase the amount of steps/day compared to
wearing the tracker without feedback. Patients who ambulate less frequently in the initial postoperative period may be
at higher risk for unplanned Emergency Department visits or readmissions. Early identification of these high-risk
patients using activity trackers would allow for increased outpatient monitoring or additional interventions to prevent
future unplanned visits.

Table 1 .

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P591

P593

A Simplified and Validated Risk Score of Malpractice Litigation

in Minimally Invasive Surgery (MIS)

The Predictive Ability of C-Reactive Protein for Complications

After Laparoscopy-Assisted Gastrectomy

Alberto Raul Ferreres, MD, PhD, FACS, hon, Rosana Trapani, MD,
Alberto Rancati, MD, Julieta Camelione, MD, University of Buenos
Aires

Kecheng Zhang, Hongqing Xi, Jianxin Cui, Bo Wei, Ning Wang,

Shibo Bian, Liangang Ma, Lin Chen, Department of General Surgery,
Chinese Peoples Liberation Army of General Hospital

Introduction: The adoption of minimally invasive procedures have increased the incidence of malpractice
litigation claims due to complications and unfavorable outcomes. In that sense the rising number of biliary
duct injuries due to laparoscopic cholecystectomy represents an example. Besides, the due standard of care
and the accomplishment of a training curve to become an expert represent additional features. All these
factors contribute to the epidemics of surgical malpractice litigation worldwide and in that sense our country
is no exception. The use of risk predictors may be useful as a tool in risk management and patient safety
policies. Our objective was to design and validate a simplified predictor score of malpractice litigation in
minimally invasive surgery
Methods and Procedures: A prediction score (PIDOM) was designed taking into account the following
variables: Patient age (under 40/ 4070/ elder than 50), patient-physician Interaction (standard/ below
standard), Disease (benign/malignant), Outcomes (as planned/ differs from planned) and Medical records
quality (fair/good) and a predictive score was organized accordingly: high risk for litigation (810), medium
risk (57) and low risk (14). In order to validate the risk score, 800 randomly medical records corresponding to minimally invasive procedures from 5 institutions performed between june 2012 and june 2013
were examined. After the assessment and risk stratification were completed, a request was submitted to the
Courts and to the five insurance companies in order to know the incidence of claims sued in the 2 years
following the surgical procedures. The statistical analysis was performed with the Anova and t tests.
Results: The procedures included the following: laparoscopic cholecystectomy: 495 (61.87 %); appendectomy 95 (11.87 %); hernia repair 61 (7.62 %); colectomy 122 (15.25 %) and splenectomy 27 (3.37 %).
The assessment of the 800 medical records was as follows: 600 (75 %) were considered as low risk; 159
(19.87 %), medium risk and 41 (5.12 %), high risk. The incidence of claims was the following: low risk
group: 4/600 (0.33 %), medium risk: 48/159 (30.18 %) and high risk: 25 (60.97 %). The most frequent
cause were biliary duct injury (28, 36 %), and visceral injury (13, 16.88 %). Results were statistically
significant.
Conclusions: The PIDOM risk score for malpractice litigation after MIS may play a role and serve as a
useful aid tool in risk management. It may serve to identify high risk patients or problematical situations
which may warrant quick and early interventions to prevent malpractice litigation in this field.

Purpose: To investigate the diagnostic accuracy of C-reactive protein (CRP) and white blood cell (WBC)
for early detection of complications following laparoscopy-assisted gastrectomy (LAG) and to construct a
nomogram for clinical dicision-making.
Methods: Clinical data of consecutive patients underwent LAG with curative intent between December
2013 and March 2015 was prospectively collected. Postoperative complications were recorded according to
the Clavien-Dindo classification. The diagnostic value of CRP and WBC was evaluated by area under the
curve (AUC) of receiver operating characteristic curve (ROC). Optimal cut-off value was determined by
Youdens index. Univariate and multivariate logistic regression analysis were conducted to identify risk
factors for complications and then a nomogram was constructed.
Results: A total of 278 patients successfully underwent laparoscopy-assisted gastrectomy. Twenty-nine
patients (10.4 %) developed major complications (grade C III). CRP on postoperative day 3 (POD3) and
WBC on POD7 had highest diagnostic accuracy for major complications with an AUC value of 0.86 [95 %
confidence interval (CI), 0.790.92] and 0.68 (95 % CI, 0.560.79) respectively. An optimal cut-off value of
17.2 mg/l was identified for CRP, yielding a sensitivity of 0.79 (95 % CI, 0.600.92) and specificity 0.74
(95 % CI, 0.680.80). Multivariate analysis identified POD3 CRP values C 17.2 mg/l, Eastern Cooperative
Oncology Group Performance Status C 1, presence of preoperative comorbidity and operation time C 240 min were risk factors for major complications after LAG.
Conclusion: CRP on POD3 and CRP-based nomogram contribute to early detection of complications after
LAG (Fig. 1).

P592
Chemical Pyloroplasty with Botulinum Toxin (Botox) During
Sleeve Gastrectomy: A Retrospective Analysis of Staple-Line
Leak Rates
Robert C Perez, MD, Vladimir Davidyuk, MD, Jason J Arellano, MD,
T. Paul Singh, MD, Brian R Binetti, MD, Daniel J Bonville, DO,
Steven C Stain, MD, Albany Medical Center
Introduction: Sleeve gastrectomy has become a leading procedure for the treatment of morbid obesity.
Staple-line leaks remain one of the most concerning complications following sleeve gastrectomy. It is
believed that increased pressure within the sleeve leads to the occurrence of staple-line leaks. Improved
gastric emptying by means of pyloroplasty should reduce intragastric pressure. The purpose of this study
was to compare the incidence of staple-line leak in patients who did and did not receive chemical
pyloroplasty via pyloric botulinum toxin (Botox) injection during sleeve gastrectomy.
Methods and Procedures: This is a retrospective analysis of 281 patients who received either robotic or
laparoscopic sleeve gastrectomy at our institution from August 2009 to July 2013. Demographic, perioperative and post-operative data were collected from the patients electronic health record (SOARIAN).
Results: A total of 281 patients underwent sleeve gastrectomy from August 2009 to July 2013. 198 (70 %)
patients received chemical pyloroplasty with pyloric Botox injection. Mean BMI in this group was
45.0 6.9 with an average age of 43.2 10.9. 83 (30 %) patients did not receive chemical pyloroplasty.
Mean BMI in this group was 44.6 6.6 with an average age of 45.8 11.4. There was no significant
difference in mean BMI, age, or gender make up between the two groups. There was no incidence of leak in
the group that received Botox for chemical pyloroplasty. The incidence was 2.41 % (2/83) in patients who
did not receive Botox (p \ 0.05).
Conclusions: Chemical pyloroplasty with pyloric Botox injection is effective in reducing staple-line leaks
when used during sleeve gastrectomy. It is a simple, effective method to prevent leak by improving gastric
emptying. Further research will evaluate the efficacy of Botox injection on other indicators such as hospital
length of stay and readmission rates.

Fig. 1 a The chronological changes of CRP concentration (median with interquartile range) for
major complications (MC) and no complications (NC). *P \ 0.05, b Receiver operating
characteristic curve (ROC) for postoperative day 3 (POD3) CRP with an AUC value of 0.86

P594
Incidence of Metastases to the Abdominal Wall Following
Percutaneous Endoscopic Gastrostomy Placement in Patients
with Head and Neck Cancer
Eleanor Fung, MD1, Edward L Jones, MD2, David Strosberg1,
Rebecca Dettorre1, Andrew Suzo1, Michael P Meara1,
Vimal K Narula1, Jeffrey W Hazey1, 1The Ohio State University
Wexner Medical Centre, 2Department of Surgery, University
of Colorado at Denver
Introduction: Patients with head and neck malignancy are often malnourished at the time of their diagnosis
and during the course of their treatment. As a result, percutaneous endoscopic gastrostomy (PEG) tubes are
an effective modality for enteral nutrition given the favorable benefit-risk profile compared to nasoenteric
tubes and surgical intervention; however, there have been documented case reports of seeding of the tract
by the theoretical risk of dragging the tube along the tumor during PEG placement in patients with head and
neck malignancy. The objective of this study is to determine the incidence and contributing risk factors
leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer.
Methods and Procedures: A retrospective chart review was performed on our database of 742 patients
diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/29/
2014. Patients without a head and neck malignancy or without 30 day follow-up after PEG placement were
excluded. The primary outcome was the development of abdominal wall metastases following PEG
placement. Secondary outcomes included type of malignancy and tumor characteristics, smoking history,
PEG placement technique, stomal metastasis presentation and survival following recurrence. Data was then
analyzed using basic analysis for overall trends.
Results: Out of 742 patients analyzed, a total of five patients with head and neck malignancy were identified
with abdominal wall metastasis following PEG tube placement for an overall incidence of 0.0067 %. One
patient was found to have a clinically evident and symptomatic stomal metastasis while the other four
patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were
found to have Stage IV cancer at time of initial diagnosis of their head & neck malignancy followed by
widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis. Furthermore, all of these patients underwent PEG tube insertion via the Pull technique.
Conclusion: Abdominal wall metastases following PEG placement are a rare but serious complication in
patients with head and neck malignancy. Potential risk factors associated with stomal metastases include
advanced cancer stage, synchronous distant metastatic disease, the Pull technique for PEG insertion,
smoking and alcohol use history as well as large primary tumor size.

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P595

P596

Clinical Significance of Surgical Energy Induced Biomolecular

Inflammatory Response Observed in Patients Undergoing
Laparoscopic SurgeryResults of a Triple Blind Randomized
Study

Common Bile Duct Perforation by Biliary Stents Post-Ercp: CaseReports and Literature Review of Management

Brij B Agarwal, MBBS, MS1, Juhil D Nanavati, MBBS1, Nayan

Agarwal, MBBS, STUDENT2, Murali K Bethanbhatla, MBBS1,
Neeraj Dhamija, MBBS, DNB1, Kumar Manish, MBBS1, Satish
Saluja, MBBS, MD1, Naveen Sharma, MBBS, MS2, Sneh Agarwal,
MBBS, MS3, 1Sir Ganga Ram Hospital & GangaRam Institute
of Postgraduate Medical Education & Research, 2University College
of Medical Sciences & GTB Hospital, New Delhi, 3Lady Hardinge
Medical College, New Delhi
Introduction: Energized dissection (ED) augments the proinflammatory cytokine response in patients undergoing laparoscopic
surgery (LS). We have reported the adverse impact of ED on clinical outcomes following LS. We now studied the clinical
significance of ED induced proinflammatory cytokine cascase.
Methods and Procedures:A Triple blind randomized study of consecutive unselected consenting candidates for day care
laparoscopic cholecystectomy (LC), an index LS. Randomization by external research coordinator (blind to perioperative observations) into Group A and Group B. Standard technique of LS with or without ED followed by surgeons (blind to pre and
postoperative observations) for the group allocated. Prospective data was collected for biochemical markers and clinical outcomes
separately by independent nonoperative researchers (blind to operative technique) and stored in online autolocking hospital
information system (HIS). Prospectively collected data for biomolecular and clinical outcomes was analysed separately by the two
researchers respectively.

STUDY POINTS - [H = Hour, D = Day, W = Week PO = Postoperative; POP = Pain, POF = Fatigue, POS = Sleep]
Study point

Molecular / Metrics

Biomolecular (H0, H4, H24)

IL6, HS-CRP, TNF-a, SGOT, SGPT, ALP, GGT, Amylase, Lipase

Clinical (D1, D3, D10, W3)

POP(100 point VAS), PONV(06 scale), POF(084 Modified

Impact scale), POS(021 Pittsburg Scale)

Prospectively collected data for biomolecular and clinical outcomes was analysed separately by the two researches respectively The
access codes for entire data in HIS will be available to all the researchers next month for cross accessing the biomolecular as well as
clinical outcomes and will be analysed for any correlation. The results will be presented at the meeting.
Conclusion: The results of any correlation of biomolecular inflammatory response to the clinical outcomes will be presented and
discussed at the meeting.

123

Nehemiah Samuel, Mr, Alex Wheeler, Dr, Muhammad H Shiwani,

Mr, Ahmed Masri, Mr, Barnsley Hospital NHS Foundation Trust
Background: Common bile duct (CBD) stones are usually treated with endoscopic retrograde cholangiopancreatography (ERCP)
with or without stent insertion; followed usually by laparoscopic cholecystectomy for gallstones. Iatrogenic CBD injury is a
recognised complication associated with high morbidity.
Patients and Methods: We report on two patients (A and B) who both had ERCPs for CBD stones and a 7fr. polyethylene pigtail
biliary stent inserted prior to elective laparoscopic cholecystectomy. Intraoperatively, in patient A the stent was seen perforating the
proximal CBD; and in patient B the stent had perorated the distal CBD with its intraperitoneal tip found to be fistulating into the
duodenum. Patient A was managed with laparoscopic closure of duct perforation site, distal choledochotomy for T-tube insertion
and a tube drain placed in the subhepatic space. In Patient B the laparoscopic procedure had to be converted to open and T-tube
inserted via the perforation site. In both cases the T-tube was clamped on day 5 followed by cholangiogram to confirm no bile
leakage prior to taking out the drains.
Results: Post-ERCP, CBD perforations are relatively rare with the incidence ranging from 0.32.1 %. The majority are caused
during the procedure due to guide-wire insertion. A small number are caused at the time of stent placement or its subsequent
migration. CBD perforation by stents could be speculated to be caused by the nature and type of stent or the duration between ERCP
and laparoscopic cholecystectomy when left in-situ.
Conclusion: Despite little evidence on the management of perforations, T-tube placement seems a rational option for allowing
perforations to heal and for further assessment of on-going leaks through cholangiography.

Surg Endosc (2016) 30:S325S500

S481

P597

P599

Institutional Review of Therapeutic Enoxaparin Hemorrhagic

Complications in Morbid Obesity

Preoperative Body Mass Index Predicts Two-Year Weight Loss

Outcomes Following Laparoscopic Fundoplication

Ellen A Carraro, MD, Dean J Mikami, MD, Bradley J Needleman,

MD, Sabrena F Noria, MD, PhD, The Ohio State Wexner Medical
Center

Lava Y Patel, MD1, Nicolas J Bonamici, BA1, Thomas J Stringer,

BA1, Joseph D Morrison, BS1, Matthew E Gitelis, BS1, Yalini
Vigneswaran, MD2, Brittany Lapin, PhD1, John G Linn, MD1,
Michael B Ujiki, MD1, 1NorthShore University HealthSystem,
2
University of Chicago Pritzker School of Medicine

Introduction: Enoxaparin, a low molecular weight heparin, is often used prophylactically to reduce the risk
of thromboembolic events, and therapeutically to bridge to full oral anticoagulation postoperatively. In
individuals with obesity (BMI [ 30 kg/m2), there is concern regarding the optimal dosing as drug distribution and pharmacokinetics may be altered. While laboratory evaluation with anti-Xa levels has been
proposed, risk of thrombosis and hemorrhage have not been shown to correlate well with anti-Xa levels.
Overall risk of major hemorrhagic complications on low molecular weight heparin is 1.1 %, however we
noted several bleeding complications in our patient population and decided to evaluate our experience and
identify risk factors that may be contribute to hemorrhagic complications.
Methods: A retrospective chart review was performed on postoperative patients discharged, from a single
surgical service, on therapeutic enoxaparin as a bridge to full anticoagulation from year start to year
finish. Demographic informations, surgical intervention and surgical complications were reviewed to
assess risks related to anticoagulation.
Results: A total of 41 patients met the inclusion criteria. The mean age was 49.8 years with 68 % females
and a mean BMI of 47.0 kg/m2. Surgical interventions included, sleeve gastrectomy (36.6 %), abdominal
wall hernia repair (26.8 %), Roux en Y gastric bypass (22 %), exploratory laparotomy (9.7 %) and others
(2.4 %). The indication for anticoagulation included a history of deep vein thrombosis/pulmonary embolism
(75.6 %), atrial fibrillation (14.6 %), portal vein thrombosis (4.9 %), and other (4.9 %). Fifteen (36.6 %)
patients were readmitted for complications directly related to their surgical intervention. Of these, 3 (7.6 %)
were admitted secondary to hemorrhagic complications and specific interventions included, (1) medical
management with blood transfusion and reversal of supratherapeutic anticoagulation, (2) transfusion and
stenting of subsequent, possible resultant, gastric sleeve leak, and (3) transfusion and empiric embolization.
Conclusions: Post-operative bridging of morbidly obese patients with therapeutic enoxaparin should be
approached with caution as the incidence of hemorrhagic complications may be greater than expected.
However, further studies are needed to identify those at increased risk of complications including more
consistent evaluation of anti-Xa levels, both at initial administration and at readmission, in order to adjust
dosing or pursue alternative options for anticoagulation.

Introduction: Weight loss following laparoscopic fundoplication has been seen in patients in the immediate
postoperative period. To date, there is no way of predicting how a fundoplication procedure will affect the
patients weight status, if at all, in the long term. Here we report the use of preoperative body mass index
(BMI) as an assessment tool to predict long-term changes in weight following this procedure.
Methods: A retrospective review of a prospectively maintained database (n = 615) at our institution was
performed. In this study, 228 patients were identified as having undergone a laparoscopic fundoplication
procedure for either GERD or PEH. Transoral incisionless fundoplication patients were excluded as were
any patients who had a redo operation or pyloroplasty during the same operation. Patients were classified
into four groups based upon BMI on the date of surgery: BMI \ 25 (n = 56), BMI 2530 (n = 83), BMI
3035 (n = 63) and BMI [ 35 (n = 26). Weight change outcomes were measured postoperatively at three
weeks (3WPO), 6 months (6MPO), one-year (1YPO), and two-years (2YPO). Comparisons between groups
were made using one-way ANOVA, and adjusted linear regression models were constructed to predict
weight loss at 2YPO.
Results: All data are presented as mean standard deviation unless otherwise stated and negative numbers
indicate weight loss. Weight change at 2YPO was significantly different between the various BMI profiles
(p \ 0.01): patients with BMI \ 25 gained 0.4 10.6 lbs, BMI 2530 lost -2.8 13.7, BMI 3035 lost
-5.3 16.3, and BMI [ 35 lost -16.9 20.8. A linear regression model showed that preoperative BMI
could significantly predict postoperative weight change at 2YPO (estimate se: -1.01 0.23, p \ 0.01).
The relationship between preoperative BMI and weight change remained intact after controlling for age and
type of fundoplication (Nissen vs Toupet vs Dor).
Conclusions: Our findings suggest preoperative BMI is a contributing factor to weight change outcomes at
two-years following laparoscopic fundoplication. Morbidly obese patients tend to lose significantly more
weight.

P598
How Do We Value Postoperative Recovery? Systematic Review
of the Measurement Properties of Patient-Reported Outcome
Instruments to Measure Recovery After Abdominal Surgery
Julio F Fiore Jr, PhD, Sabrina Figueiredo, MSc, Lawrence Lee, PhD,
Benedicte Nauche, MLIS, Nancy Mayo, PhD, Liane S Feldman, MD,
McGill University Health Centre
Introduction: Patients and caregivers actively seek information about how long it will take to recover or
get back to normal after an operation. Surgical techniques (e.g. laparoscopy) and perioperative care
programs (e.g. enhanced recovery pathways) are widely advocated to improve recovery. In line with the
principles of patient-centered care, measurement of recovery needs to include the patients voice through
patient-reported outcomes (PROs; reports of health coming directly from the patient without interpretation
by others). To draw valid conclusions regarding PRO data, instruments with robust measurement properties
are required. The aim of this systematic review is to summarize and critically appraise the measurement
properties of PRO instruments used in the context of postoperative recovery after abdominal surgery.
Methods: This review followed the PRISMA guidelines and was registered at PROSPERO
(CRD42014014349). Eight bibliographic databases (MEDLINE, EMBASE, Biosis, PsycINFO, PubMed,
CINAHL, Scopus, Web of Science) were searched. Studies were included if they (1) focused on evaluating
the measurement properties of PROs used in the context of postoperative recovery (i.e. \3 months after the
operation) and (2) involved adult patients ([18 yo) undergoing abdominal surgery. We excluded studies
involving instruments that were specific to a single domain (e.g. pain, fatigue) or disease/organ specific (i.e.
reflux, bariatric surgery). The measurement properties of each instrument were appraised using the
COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.
Results: We identified 29 studies evaluating 19 different instruments. Fifteen instruments were recoveryspecific (4 specifically focused on abdominal surgery) and 3 were generic instruments having their measurement properties assessed in the context of recovery. Only 2 instruments had content validity supported
by qualitative research (Abdominal Surgery Impact Scale and Postoperative Recovery Profile). Evidence for
internal consistency, reliability, structural validity, construct validity, cross-cultural validity and responsiveness was generally poor/limited. Instruments widely used in the literature such as the Quality of
Recovery-40 and SF-36 had conflicting results in regards to construct validity and responsiveness. None of
the instruments identified were developed according to the FDA guidelines for PROs or used modern
psychometric methods to optimize item selection and scoring (e.g. Item-Response Theory).
Conclusions: There is very limited evidence supporting the measurement properties of existing PRO
instruments used in the context of recovery after abdominal surgery. This should be taken into account when
interpreting results from studies using these instruments. Measuring the value of innovations advocated to
improve recovery requires the development of recovery-specific PRO instruments according to FDA
standards.

P600
Treatment of High-Output Thorasic Chyle Fistula
with Transabdominal Embolization of Cysterna Chyli: A Case
Report
Oguzhan Ozsay2, Osman Nuri Dilek1, Volkan Cakir2, Selda Gucek
Haciyanli2, Omur Balli2, Emine Ozlem Gur1, Mehmet Haciyanli1,
2
Ataturk Research and Education Hospital, 1Katip Celebi University
School of Medicine
Postoperative thorasic chylous fistula is an infrequent complication after esophageal surgery that represents
a difficult management problem due to the serious mechanical, nutritional and immunological consequences
of the constant loss of protein and lymphocytes. Management varies from conservative treatment with
drainage, intravenous nutrition, medical management with different drugs applications, treatment and
prevention of septic complications, lymphangiography for ductal embolization, to re-operation, either by
thoracotomy or laparotomy to control the fistula.
A 65-year-old woman sequentially developed a high-output (2500 ml/day) thorasic chylous fistula and rightsided chylothorax, after a transhiatal total esophagectomy for adenocarcinoma of the distal esophagus.
Multimodal procedures including low-triglyceride diet, sclerosing agens, repeated thoracentesis, and closed
thoracostomy tube drainage had been applied for treatment within two months after surgery. Finally,
embolization of the cysterna chyli with liquid embolic agents produced rapid clinical and radiographic
improvement. The procedure of opacification, catheterization, and embolization of the cysterna chyli was
successful.
Percutaneous transabdominal duct embolization is a safe, effective, and minimally invasive option for
treating chylothorax. Here in, we discussed the case and treatment modalities in view of the literature.

123

S482

Surg Endosc (2016) 30:S325S500

P601

P603

Successful Peritoneal Dialysis Program from a Surgical

Perspective: A Case Series of Laparoscopic Peritoneal Dialysis
Catheter Patients

Surgical Outcomes of Patients with Cirrhotic or Non-Cirrhotic

Liver Disease in an Acute Care Setting: An Analysis
of the Nationwide Inpatient Sample

Sarah Markham, Wayne S Lee, MD, Tony Chan, MD, Jonathan D

Svahn, MD, FACS, Department of Surgery, Kaiser Permanente
Oakland, California

Punam V Patel, MD, Sri Ram Pentakota, MD, MPH, PHD, Aziz
Merchant, MD, Rutgers - NJMS

Introduction: Laparoscopic peritoneal dialysis (PD) catheter placement has been shown to have equal or
better outcomes compared to other approaches. In the US, only 7 % of all patients initiating dialysis
treatment started PD. Kaiser Permanente Northern California has one of the highest proportions of patients
starting dialysis on PD (25 %). At Kaiser Oakland during the study period, 51 % of patients started PD. Our
objective was to analyze the PD placement of these patients from a surgical perspective.
Methods: A retrospective review was performed on consecutive patients initiating dialysis from February
2013 to January 2014 at a single institution, with a subset analysis of those who underwent laparoscopic PD
placement by two attending surgeons. Patient characteristics, operative data, and complications were
analyzed.
Results: In 50 PD catheter patients, mean age was 59.2 with slight predominance of males (55.1 %).
Average BMI was 29.2. Twenty percent had previous surgery, and 24 % had the PD catheters placed on an
urgent basis. Average case length was 46.1 minutes. There were four complications (8 %) due to exit site
infections. This was associated with the case length (p \ 0.05). Case length was associated with urgent
procedures, but not with history of previous surgery or body mass index. There was also a difference in
operative time between attending surgeons likely due to experience.
Conclusion: Laparoscopic PD catheter insertion is a safe minimally invasive procedure with short operative
time. In conjunction with experienced nephrologists and PD nursing unit, surgeons can help facilitate a high
PD rate with low complications.

Introduction: Morbidity and mortality in patients with liver disease undergoing surgical intervention is
known to be greater than the average patient, however the type of disease is rarely differentiated. We
analyzed data from the Nationwide Inpatient Sample to determine the association of type of liver disease and
type of surgery on surgical outcomes.
Methods: The Nationwide Inpatient Sample from 20062010 was used to identify patients undergoing
specified general surgical interventions in an acute care setting. These patients were categorized as cirrhotic,
non-cirrhotic and those with no liver disease. Study outcomes were in-hospital mortality, any surgical
complication and any medical complications. Descriptive statistics were calculated using proportions (for
categorical variables) and mean and standard deviation (SD) (for continuous variables). Unadjusted and
adjusted logistic regression models were fit to assess the association between type of liver disease and the
study outcomes. Covariates included were age, race, gender, payer type, number of comorbid conditions, lap
versus open surgery.
Results: Of the 893861 patients identified, 11343 (1.27 %), 15138 (1.69 %), and 867200 (97.04 %) had
diagnoses of cirrhotic liver disease, non-cirrhotic liver disease and no liver disease, respectively. The mean
age of the overall cohort was 52.97 years (SD 19.97). The cohort was 55 % white; mostly female (58.51 %)
and had private (41 %) or government (44 %) insurance. Overall, 70 % of patients had at least one chronic
comorbid condition. Laparoscopic surgery was performed in 49.78 % of patients. Complication rates in the
overall cohort were 3 %, 8.1 %, and 22.8 % for in-hospital mortality, surgical, and medical complications,
respectively.

Type of liver disease

P602

Overall Mortality#

Surgical complications#

Medical complications#

cirrhotic vs none

2.89 (2.703.10)

1.35 (1.281.43)

1.49 (1.431.55)

non-cirrhotic vs none

1.45 (1.311.61)

1.09 (1.021.16)

1.03 (0.991.08)

A Novel Approach at Reducing Avoidable Post-Bariatric Surgery

ER Visits And Readmissions

cirrhotic vs non-cirrhotic

1.99 (1.762.25)

1.24 (1.141.35)

1.45 (1.371.54)

laparoscopic vs open

0.11 (0.110.12)

0.17 (0.160.17)

0.57 (0.560.58)

Van S Leavitt, DO, David Podkameni, MD, Flavia Soto, MD, Albert
Chen, MD, Emil Graf, MD, Jill Gorsuch, DO, MPH, Sarah
Whitehead, Banner Gateway Medical Center

# Adjusted Odds Ratios from multivariable logistic regression models; Variables: type of liver disease, age,
gender, race, payer type, number of chronic comorbidities, and lap/open surgery

Introduction: Emergency room (ER) visits and hospital readmissions after bariatric surgery are estimated
by the American College of Surgeons to be 5.22 %. Many of these ER visits and readmissions are
potentially avoidable with close post-operative monitoring and follow up. In an effort to reduce postoperative readmission rates at one community center of excellence, a program of frequent post-op phone calls
has been employed. Patients are called every other day for the first two weeks following bariatric surgery
and are asked a series of questions addressing early warning signs of potential readmission. The aim is to
reduce avoidable ER visits and readmissions through a telephone triage system.
Methods and Procedures: Since March of 2015, patients undergoing bariatric procedures were placed on a
call list and contacted by one of the bariatric surgeons every other day for the first two weeks following
surgery. A standard list of questions is asked which addressed the most commonly identified reasons for
hospital visit after surgery. Recommendations are made, questions addressed and reassurance is given to the
patients. In the period of time from March 2015 until August 2015, 160 bariatric procedures were performed
mostly consisting of Roux-en-Y gastric bypass and laparoscopic vertical sleeve gastrectomies. The rate of
ER visits and readmissions, which is closely tracked by the institution, was compared to those from exactly
one-year prior.
Results: A retrospective analysis of the bariatric surgery database between March and August of 2014
showed that the number of bariatric procedures performed was 152. The number of ER visits after surgery in
2014 was 15. This results in a 9.8 % ER/readmission rate at this institution. In 2015 with 160 cases done and
16 ER/readmissions, the rate climbed to 10 %. One patient in the 2015 data accounted for 3 separate ER
visits despite multiple phone conversations. When this patients data is added as one occurrence the percentage falls to 8.75 %. The nature of the ER visits did not change significantly with non-specific abdominal
pain being the leading cause of ER visitation.
Conclusions: As the health care system increasingly scrutinizes surgeons and their patient outcomes it
behooves us to find new methods for triaging patients and addressing their concerns in an outpatient setting.
While the data from this institution is not demonstrating considerable change currently, it is felt that over
time the frequent contact will help decrease the need for patients to seek post-operative care in the ER.

123

Conclusions: Based on our cohort, patients with cirrhotic disease are at increased risk for poor outcomes
when compared to those with non-cirrhotic disease. Patients undergoing laparoscopic surgery have significantly favorable outcomes compared to those undergoing open surgery.

P604
Video Analysis of Surgery: Defining the Data Set of the Future
Oliver A Varban, MD, FACS1, Adam Niemann, BS2, Jon Schram,
MD3, Arthur M Carlin, MD, FACS4, Steven C Poplawski, MD,
FACS5, Justin B Dimick, MD, MPH, FACS1, 1University
of Michigan Health System, 2University of Michigan School
of Medicine, 3Spectrum Health Medical Group, MI, 4Wayne State
University, Henry Ford Health System, 5Forest Health Medical
Center
Background: It has been shown that variations in surgical outcomes can be correlated directly to video
based peer-rated evaluation of surgical skill. However, little is known about the use of surgical videos to
identify variations in operative technique and how they may affect outcomes.
Methods: Representative videos of laparoscopic sleeve gastrectomy were voluntarily submitted by 20
surgeons who participate in the Michigan Bariatric Surgery Collaborative, a statewide consortium that uses a
clinical data registry for quality improvement. Each video was devoid of patient identifiers and edited so as
to exclude port placement, tissue extraction and camera exchanges. Time to completion of each step was
assessed as well as variations in the tasks performed during each step.
Results: Twenty-two videos of laparoscopic sleeve gastrectomy were submitted and 11 included concurrent
hiatal hernia repair. Data obtained from video identified variation in time to completion of each step of the
procedure as well as differences in management of hiatal hernias, stapling technique and management of
staple line. Mean time to completion for unedited videos was 47 minutes without hiatal hernia repair (range
2866 min) and 55 min with hiatal hernia repair (range 3480 min). Among cases involving hiatal hernia
repair, 55 % performed a posterior cruropexy, 27 % performed an anterior cruropexy and 18 % performed
both. Two different vendors and 10 different permutations of staple heights and buttressing material was
used during division of the stomach. The median number of staple cartridges used was 6 (range 47).
Management of the staple line included: use of buttressing (64 %), fibrin sealant (36 %), oversewing (9 %),
use of surgical clips (18 %), imbrication of the staple line (36 %) and omentoplasty (55 %). A leak test was
performed in 50 % of cases and endoscopy was performed in 17 % of cases. Drains were placed 9 % of the
time.
Conclusions: Video analysis of laparoscopic sleeve gastrectomy provides a unique dataset that highlights
variation in: 1) time to completion of each step of the procedure, 2) variation in hiatal hernia repair, 3)
variation in stapling technique and 4) variation in staple line management. Video-based data of technique
can be further augmented with peer-reviewed assessment of skill and also combined with a clinical outcomes registry for a robust comparative analysis on the effect of specific techniques, devices and skill on
outcomes, cost and quality.

Surg Endosc (2016) 30:S325S500

S483

P605

P607

Biliary Stent Migration Presented as Abdominal Wall Abscess:

Case Report and Literature Review

The Quality of Survey Methodology in the Surgical Literature:

A Call for Publication Guidelines?

Hany Fahmy, MD, FRCSI, FACS, Ahmed Elsayed, Ahmed Dwid,

Royal Commission Medical Center

Sami Chadi, MD1, Biniam Kidane, MD2, Patrick H Colquhoun, MD3,

Nawar AlKhamesi, MD3, Christopher M Schlachta3, Steven D
Wexner, MD, PhD, Hon1, 1Digestive Disease Center, Cleveland
Clinic Florida, 2Division of Thoracic Surgery, University of Toronto,
Toronto, Canada, 3Division of General Surgery, Western University,
London, Canada

Endoscopic biliary stenting is a well-established and minimally invasive procedure for the
treatment of biliary tract obstruction. Several complications of stent placement have been
described. Stent migration is a late complication which usually passes spontaneously.
Rarely, it may lead to perforation or penetration with consequent serious complications.
After reviewing the literature concerning strange presentations of migrating biliary stent,
very few case reports described anterior abdominal wall abscess as a presentation of
migrating biliary stent. This case report and review literature describes strange presentations of migrating biliary stent and presents the unusual anterior abdominal wall abscess
due to the migration of a biliary stent with successful percutaneous extraction.
Report concludes the importance of high index of suspicion and close surveillance after
biliary stent placement to reduce the chance of serious events. Also, management option of
a migrated biliary stent should depend on the patients clinical condition and stent location.
The objective in presenting this case and reviewing the literature is to highlight bowel
penetration and anterior abdominal wall abscess as a rarely seen complication of biliary
stent migration which was successfully treated by percutaneous retrieval.
Keywords: Biliary stent, stent migration, abdominal wall abscess

P606
Cost of Robotic Hernia Surgery
Amareshewar Chiruvella, MD, Daniel Lomelin, MPH, Vishal
Kothari, MD, Dmitry Oleynikov, MD, University of Nebraska
Medical Center
Introduction: Robotic technology has been incorporated into the field of general surgery to
help overcome the limitations of standard laparoscopy. Robot-assisted (RA) surgery has
been found to be costlier than its laparoscopic counterpart. More recently, use of robotassistance in hernia repair has been observed to be similar to standard laparoscopy in
outcomes, but also being more expensive. This study examines the cost of RA inguinal
(RA-IHR) and ventral (RA-VHR) hernia repair in the University HealthSystem Consortium
(UHC) database to determine the specific areas of increased cost when compared to
laparoscopy.
Methods: The UHC is an alliance of more than 100 academic medical centers and 200
affiliated hospitals. Data from the Clinical Database/Resource Manager online tool was
queried for encounters from 20112015 using the ICD-9 codes for RA and laparoscopic
inguinal hernia repair (L-IHR), as well as RA and laparoscopic ventral hernia repair (LVHR). Cost, morbidity, mortality, and readmission were examined for analysis using IBM
SPSS v20.0.0.0.
Results: A total of 31,183 (RA: N = 842, Lap: N = 30,341) patients underwent IHR while
11,351 (RA: N = 375, Lap: N = 10,976) had surgery for VHR. There was no difference in
the morbidity (p \ 0.001), or readmission rates (p \ 0.03) between L-IHR and R-IHR
groups.
Overall, the mean cost of L-IHR was $3,705 while that of RA-IHR was $5,399, representing an increase of 46 %. The mean cost of L-VHR was $3,586 while that of RA-VHR
was $6,377, an increase of 77 %.
Cost breakdown by UHC-established service groups revealed that the primary cost differences were incurred for OR services and cost of surgical supplies. The OR services
category, which includes labor, was the largest contributor to the cost increase in RA cases.
OR services alone added $1,884 to the cost of RA-IHR compared to L-IHR. Likewise, these
categories resulted in an additional cost of $1,672 for RA-VHR. Other categories reported
by UHC include accommodations, ancillary services and anesthesia. However, the differences among these cost areas were negligibly small between laparoscopic and RA
procedures.
Conclusions: While the dexterity of the robot has facilitated minimally invasive surgery
across different specialties, its use has been consistently shown to incur higher costs. This
study shows that the major increases in cost from robot use are found in areas such as labor,
rather than supplies. Future studies need to include fixed and variable costs of new technology to better understand the ultimate utility of these devices.

Introduction: Survey research is an important step in current quantitative and qualitative

research methods. Reviews of survey methodology in critical care and nephrology have
demonstrated a need for standards. The objective of this study was to review current
standards of survey methods and reporting in the surgical literature.
Methods: All issues of 8 surgical journals were reviewed to identify surveys of health
professionals between 20022013, excluding mixed-methods studies and surveys of
specific interventions (4 general: Journal of the American College of Surgeons, Surgical
Endoscopy, Annals of Surgery and World Journal of Surgery; 4 subspecialty: Journal of
Pediatric Surgery, Journal of Vascular Surgery, Diseases of the Colon and Rectum, Annals
of Surgical Oncology). Four other journals were initially included a priori that were subsequently excluded due to (1) no surveys being published, (2) publication of articles for
only a part of the cohort. The main outcome was the overall transparency and quality of
surveys (5 point Likert scale).
Results: We included 219 surveys in this review. Overall inter-rater reliability was strong
for both publication transparency (weighted j 0.8; 0.670.93) and publication quality
(weighted j 0.83; 0.720.93). The median response rate was 62 %. The most common
method of survey dissemination was email (46 %) followed by postal (33 %), with 20 %
using multiple methods. Publication rates were assessed per 1000 citations from each
journal per year. No overall trend of increasing publication rate was identified (p = 0.43)
although there was evidence of differing rates of publication among journals (p \ 0.001).
Although 48 % reported sending reminders, 46 % did not report whether this was done.
Regarding instrument development, item generation and item reduction were mentioned in
11.6 % and 2.5 % of papers. Regarding instrument testing, 19 % of papers piloted their
instrument prior to dissemination whereas clinimetric properties of at least one of face,
content, construct validity, intra- or inter-rater reliability, or consistency were mentioned in
less than 13 % of studies. Median quality and transparency scores were 3. Higher survey
quality (as determined by reviewers) appeared associated with reporting a previously
published instrument (OR 3.0; p \ 0.001), single survey metric (OR 22.0; p \ 0.001) and
discussing the management of incomplete surveys (OR 2.9; p = 0.014).
Conclusion: The quality of survey methods and reporting is suboptimal in the surgical
literature. In particular, reporting survey metrics and instrument testing appears to need
significant improvement, with even lower rates than the medical literature. Guidelines of
reporting and methods are necessary to standardize and improve quality.

P608
Claims and Outcomes of Lawsuits After Antireflux Surgery
in the United States
Joshua A Boys, MD1, Brian Hoffman, JD2, Daniel S Oh, MD1, Jeffrey
A Hagen, MD1, Brenda Radmacher, JD2, Evan T Alicuben, MD1,
Steven R DeMeester, MD1, 1University of Southern California, Keck
School of Medicine, Los Angeles, California, 2Wood Smith Henning
& Berman
Objective: Antireflux surgery should have a low morbidity rate. Major complications might
lead to a lawsuit. The aim of this study was to determine factors that led to a lawsuit after
antireflux surgery and the outcome of the lawsuit.
Methods: We queried two major legal databases, the Physician Insurers Association of
America and the Westlaw database, for liability claims related to antireflux surgery from
20042013.
Results: There were 175 claims. Three medical factors led to 82 % of all claims: improper
performance of the procedure (68 %), failure to recognize a complication (9 %) and errors
in diagnosis (5 %). The most common injury leading to a claim was perforation. Of the 175
claims, 81 (46 %) were withdrawn or dismissed, 55 (32 %) settled or were arbitrated, 34
(19 %) went to a trial verdict and in 5 (3 %) the disposition was unknown. The average
settlement or arbitration award was $331,354. In the 34 cases that went to a trial verdict 32
were found in favor of the defense. Of the 2 trial verdicts for the plaintiff the award ($1.5
million) was known in one case. The claim associated with a trial verdict case was known
for 12 of the 34 cases and in 7 it was related to a perforation. Overall, a claim related to
perforation led to payment in only 28 % of cases.
Conclusion: Lawsuits after a fundoplication were usually related to improper performance
of the procedure or failure to recognize or manage complications. Perforation was the most
common injury leading to a claim, but most commonly was not associated with a monetary
payment. Trials that went to a verdict were nearly always found for the defense. Therefore,
when appropriate, surgeons should insist on a trial.

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Surg Endosc (2016) 30:S325S500

P609

P611

Hormonal Status and Post-Surgical Hair Loss in Female Bariatric

Patients

Structured Early Ambulation Protocols and Post-Operative Pain

Following Laparoscopic Sleeve Gastrectomy: Is There
a Relationship?

Ami Rao-Zawadzki, Timothy M Farrell, MD, David W Overby, MD,

UNC School of Medicine
Introduction: Hair loss is a common complaint among women post-bariatric surgery; the degree and
etiology are not well-studied. With previously reported data showing increased serum FSH, LH, SHBG, and
decreased estradiol, testosterone, and DHEA-S after bariatric surgery [1], we hypothesized that a temporary
hypo-estrogenized state is present after surgery, and that questionnaire proxies for estrogen fluctuations (rate
of weight loss, vaginal lubrication, sudden resumption of menstruation) would be positively correlated with
severity of post-surgical hair loss.
Methods: Questionnaires were mailed to 253 female patients age 1860 who received gastric bypass, sleeve
gastrectomy, or gastric banding at UNC between 01/01/2010 to 01/01/2014. Eligible patients were identified
by retrospective chart review, with exclusion criteria of previous bariatric surgery or post-operative complication causing re-admission/surgical intervention. Hierarchical multiple regression analysis [SPSS]
controlled for pre-surgical hair loss, procedure type, family history of hair loss, and vitamin/protein deficiency. Final sample size was n = 53 (23 % response rate).
Results: Hair loss after bariatric surgery affected 77 % of surveyed women. Weight loss in the first year
post-surgery independently correlated with increased hair loss (p = 0.004), after controlling for protein
deficiency (p = 0.005). Vaginal lubrication (p = 0.046) and sudden resumption of menstruation
(p = 0.001) also positively correlated. No correlation was detected with age at surgery; that analysis may
have been impacted by the high rate of hysterectomy before age 55 (n = 13, 25 %).
Conclusions: Significant correlations of weight loss rate, increased vaginal lubrication and resumption of
menstruation support the role of estrogen fluctuations, as estimated by questionnaire proxies, in bariatric
post-surgical hair loss. We believe this is a novel insight, and propose future studies using direct serum
markers for further analysis.
[1] Sarwer et al. (2014) Changes in sexual functioning and sex hormone levels in women following bariatric
surgery. JAMA Surgery, 149:2633.
Independent Variables Correlated with Post-Surgical Hair Loss
Variable

Std. Error

Beta

Sig

Pre-Surgical Hair Loss

0.585

0.127

0.498

4.608

\0.001

Protein Deficiency

1.071

0.359

0.311

2.979

0.005

Weight Loss in First Year

0.018

0.006

0.348

3.066

0.004

Increased Vaginal Lubrication

0.359

0.174

0.240

2.064

0.046

Sudden Resumption Menstruation

2.934

0.825

0.407

3.557

0.001

Brian Housman, MD, Prasanthi Sunkesula, MD, Krystyna Kabata,

PA, Anthony Tortolani, MD, Piotr Gorecki, MD, New York
Methodist Hospital
Introduction: Early ambulation following abdominal operations has been linked to reduced postoperative
pulmonary and thromboembolic complications. However little data is available to support this relationship
and evaluate patient compliance with structured early ambulation protocols (SEAP). In this study we
evaluate this relationship and examine the effect of SEAP after Laparoscopic Sleeve Gastrectomy (LSG) on
post-operative pain and thromboembolic complications.
Methods: All patients undergoing primary LSG between September 2014 and August 2015 at a single
institution performed by a single surgeon (PG) were included. All patients were operated utilizing the same
technique and the same perioperative pain management protocols and thromboembolic prophylaxis with
subcutaneous Heparin and sequential compression stockings. Patients, residents and nursing staff were all
instructed and educated on potential benefits of early ambulation and formal protocols were in place as part
of the quality improvement initiative. Routine postoperative orders were in given to encourage, assist and
ambulate patients within 2 hours after returning to the floor and Every 4 hours for 24 h and until discharge.
A structured surveys were given to both nurses and patients asking whether or not patients ambulated
following surgery at three distinct time points; within 2 hours, within 6 hours, and every 4 hours thereafter.
Results: There were no perioperative mortalities and no reoperations. There were no conversions, no
intraoperative complications and no intraoperative blood transfusions. The median postoperative hospital
stay was one day. All 112 (100 %) patients ambulated within the first 24 hours; 87 (78 %) within 2 hours,
104 (93 %) within 6 hours, and 87 (78 %) every 4 hours. Of the reasons listed for not ambulating, Pain
(17 %) was the most common, followed by Fatigue (13 %), Dizziness (8.0 %) and Breathing Difficulty
(7.1 %), The Abdomen was the most common site of pain (69 %), but incisional pain (8.9 %) and chest pain
(8.0 %) were also reported. 109 patients (97.3 %) reported overall satisfaction with their pain control.
Average pain scores (010) for Ambulators were significantly lower as compared to Non-Ambulators
(within 2 hours 2.32 and 4.24 (p = 0.0056), within 6 hours 2.58 and 5.00 (p = 0.0157), and every 4 hours
2.33 and 4.20, (p = 0.0041) respectively). None of the patients experienced thromboembolic or pulmonary
complication.
Discussion: There is a strong positive correlation between lower post-operative pain scores and compliance
with strict and structured early post LSG ambulation protocols. Further studies are needed to determine
potential other and longer term clinical significance of SEAP.

P612

P610

Impact of Resection Type for Adenocarcinoma and Carcinoid

Tumors of the Small Intestine: A Review of the NSQIP Dataset

Comparison Between Laparoscopic Surgery Versus Open

Surgery in Patients with Interstitial Lung Disease

Joseph Broucek, MD, Randal Zhou, MD, John Kubasiak, MD,

Jennifer Poirier, PhD, Jonathan Myers, MD, FACS, Minh Luu, MD,
FACS, Rush University Medical Center

Kentaro Hayashi, MD1, Nobuyasu Kano, MD1, Kei Nakashima, MD2,

Hiroshi Sugimura, MD3, Hiroshi Kusanagi, MD1, 1Kameda Medical
Center Gastroenterological Surgery, 2Kameda Medical Center
Respiratory Medicine, 3Kameda Medical Center Thoracic Surgery
Introduction: Patients with interstitial lung disease (ILD) have high incidence of postoperative pulmonary
complications after lung resection. But there is little data about these complications in ILD after abdominal
surgery. Especially, there is no data of complications in ILD patients after Laparoscopic surgery.
Laparoscopic surgery needs artificial pneumoperitoneum which restricts pulmonary function. This condition
may be serious for some ILD patients.

The objective of this study is to examine whether laparoscopic surgery should be used for
ILD patients, or not.
Materials and Methods: We examined clinical data of patients diagnosed as ILD in Kameda Medical
Center, then selected all of the 57 patients who underwent abdominal surgery under general anesthesia
during 20052015. Twenty-three patients underwent laparoscopic surgery, and open surgery was performed
in 34 patients. We collected clinical data of these patients and compared laparoscopic surgery group with
open surgery group retrospectively.
Results: In comparison between laparoscopic surgery group (n = 23) and open surgery group (n = 34),
median age (75: 79.5, P \ 0.05), males (16:22 P = 0.78), median operation time (173 min: 143 min,
P = 0.17), median estimated blood loss (30 ml: 265 ml, P \ 0.05), emergency cases (4:14, P = 0.08),
perioperative complications defined as Clavien-Dindo Classification [=2 (4:10, P = 0.36), pulmonary
complications (1:5, P = 0.39), acute exacerbations of ILD in 30 days (1:3, P = 0.64) and postoperative
mortality cases (1:3, P = 0.64) were found respectively

All of the 4 cases with acute exacerbations of ILD in 30 days are emergency operations.
Conclusions: Laparoscopic surgery is not an aggravating factor for ILD in comparison with open surgery.
An emergency operation has relatively high risk for acute exacerbations of ILD in both of laparoscopic
surgery and open surgery. But as far as abdominal operations are performed electively, ILD patients may not
have high risk of acute exacerbations as those who are scheduled to undergo lung operations.

123

Introduction: Malignancies of the small intestine are a rare entity, which have been primarily treated via
open surgical resection. As the field of minimally invasive surgery continues to expand, more oncologic
resections are being performed in a minimally invasive manner without sacrificing oncologic outcomes. We
utilized the prospective ACS-NSQIP dataset to evaluate demographics, co-morbidities and short-term
outcomes of laparoscopic versus open resection of adenocarcinoma and carcinoid tumors of the small bowel.
Methods: The ACS-NSQIP dataset was queried for patients undergoing laparoscopic or open small bowel
resection for adenocarcinoma or carcinoid tumors using primary procedure CPT codes between the years
20092012. Main outcomes investigated included post-operative pneumonia, pulmonary embolism, wound
infection, re-bleeding, renal failure, DVT, sepsis/shock, cardiac events, neurologic events, return to operating room, and length of stay as defined by the ACS-NSQIP. Univariate and multivariate analyses were
used to investigate these outcomes as well as demographics for patients undergoing open or laparoscopic
(lap) resection.
Results: Regarding adenocarcinoma of the small bowel, 594 cases were identified with 14 % of resections
performed laparoscopic and 86 % of resections performed via open technique. Age was significantly different at 40.1 years old for the laparoscopic group and 44 years old for the open group (p = 0.02). Sex was
evenly distributed: 56.4 % male vs 43.6 % female (p = 0.06). When using Fishers exact test, there was a
significant different in length of hospital stay (mean lap 5.44 days [SD 2.91] vs open 8.49 [SD 5.61],
p = 0.000000006). Regarding carcinoid of the small intestine, 412 cases were identified with 15 % of cases
performed laparoscopic and 85 % open. The age was evenly distributed at an average of 47.8 years (lap 50.8
vs open 47.3, p = 0.08). Sex was not significantly different (60 % male vs 40 % female, p = 0.2). Again,
using Fishers exact test, there was a significant difference in length of hospital stay (mean lap 5.1 days [SD
4.85] vs open 7.9 [SD 5.77], p = 0.05).
Conclusion: There is evidence of low utilization of laparoscopy in the resection of small bowel malignancies. We show that laparoscopic resection is associated with a decreased length of hospital stay in these
instances.

Surg Endosc (2016) 30:S325S500

S485

P613

P615

Impact of an Enhanced Recovery Program (ERP) on Clinical

Outcomes and Institutional Costs in Elective Laparoscopic
Colorectal Resections

Clinical Efficacy of Enhanced Recovery After Surgery

in the Radical Gastrectomy for Gastric Cancer: A Prospective
Study

Carlo V. Feo, MD, FACS1, Mattia Portinari, MD1, Simona Ascanelli,

MD1, Simone Targa1, Maria Elisabete Dos Santos Valgode, RN1,
Barbara Bonvento2, Emidia Vagnoni2, Stefano Camerani3, Marco
Verri, MD3, Carlo Alberto Volta3, 1Department of Surgery,
University of Ferrara, Ferrara, Italy, 2Department of Economy,
University of Ferrara, Ferrara, Italy, 3Department of Anesthesiology,
University of Ferrara, Ferrara, Italy

Yanbing Zhou, Cheng Meng, Shougen Cao, Affiliated Hospital

of Qingdao University

Objectives: To determine the impact on postoperative recovery and cost-effectiveness of a standardized

enhanced recovery program (ERP) for colorectal surgery.
Methods: A prospective series of patients (N = 76) undergoing elective colorectal resection completing a
standardized ERP in 20132015 (ERP group) was compared to patients (N = 74) operated on at the same
academic hospital in 20102011 (conventional group), before the introduction of the ERP methodology. The
exclusion criteria for both groups were: age[80 years old, ASA score IV, TNM stage IV, and inflammatory
bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and
readmission rate in-between groups were compared. Direct costs related to the preoperative phase and
hospitalization, and implementation of the ERP were collected. Data were analyzed using chi-square,
t-Student, log-rank tests, and Cox regression analysis.
Results: Age, gender, and BMI were comparable in-between groups. Outcome variables and institutional
costs are shown in the table. After adjusting for potential confounders, following a conventional perioperative protocol was the only factor associated to prolonged hospital LOS (P \ 0.001).
Conclusion: Implementing an ERP in elective colorectal surgery: 1) significantly reduced time to functional
recovery and postoperative hospital LOS; 2) did not increase morbidity, mortality, and 30-day readmissions;
and 3) significantly decreased institutional costs.
Study funded by the Italian Ministry of Health
Variables

Conventional
Group (N = 74)

ERP Group
(N = 76)

Time to solid food (days)*

5(56)

3(23)

\0.001

Time to bowel movements (days)*

5(46)

3(24)

\0.001

Pain control on oral analgesic (days)*

4(35)

3(34)

0.019

Grade I

3(4.0)

7(9.2)

Grade II

12(16.2)

15(19.7)

Grade IIIa

1(1.4)

Grade IIIb

1(1.4)

1(1.3)

30 days mortality

Hospital length of stay (days)*

8(79)

4(46)

30 days re-admission

3(4.0)

1(1.3)

0.363

Total institutional costs per patient(USD)

8.893,36 5.708,83

5.756,24 1.735,30

0.001

Postoperative complications (Clavien-Dindo)

0.549

Objective: To investigate the clinical efficacy of enhanced recovery after surgery (ERAS) in the radical
gastrectomy for gastric cancer.
Methods: A doubleblind, randomized, controlled study was performed in the 140 patients, and all of them
were divided into the ERAS group and the control group based on a random number table. The inflammatory
markers, nutritional index and postoperative recovery of patients were observed.
Results: The total protein in serum (TP), albumin (Alb), prealbumin, TNFa, IL-6, creactive protein, resting
energy expenditure (REE), glycemic index, insulin index and Insulin resistance index in the 2 groups
showed a range of variations at postoperative day 1, 3, and 5, and these were (61 5) g/L, (34 3) g/L,
(160 18) g/L, (12.3 2.3) mmol/L, (101 34) ng/L, (43 11) g/L, (1 336 105) kal/d, (7.6 0.8)
mmol/L, (16.8 3.5) mU/L and 5.7 1.3 in the ERAS group at postoperative day 1, and (58 4) g/L,
(31 4) g/L, (147 18) g/L, (15.3 2.2) mmol/L, (122 37) ng/L, (56 27) g/L, (1 450 164) kal/d,
(9.3 1.4) mmol/L, (30.5 6.8) mU/L and 12.5 3.2 in the control group, respectively, showing a
significant difference between the 2 groups (F = 31.63, 8.03, 67.36, 147.04, 9.63, 6.84, 16.10, 54.85,
104.51, 139.47, P \ 0.05). The duration of fever, time to flatus, duration of hospital stay, hospital expenses,
numeric rating scale and quality of life (QOL) were (2.9 0.9) days, (2.9 0.6) days, (7.6 2.1) days,
(28 495 4 722) yuan, 1.4 1.0 and 15.4 0.9 in the ERAS group after operation, and (3.8 0.6) days,
(3.5 0.7) days, (8.9 2.6) days, (35 318 7 610) yuan, 2.4 1.1 and 14.4 1.2 in the control group,
respectively, with a significant difference between the 2 groups (t = -0.91, -3.66, -2.85, -4.82, -4.20,
3.92, P \ 0.05). Two patients were complicated with respiratory diseases, 1 patient received reoperation and
1 was readmitted to the hospital at postoperative day 30 in the ERAS group. Three patients had respiratory
diseases, 1 received reoperation and 2 were readmitted to the hospital at postoperative day 30 in the control
group, with no significant difference between the 2 groups (P [ 0.05).
Conclusions: ERAS is safe and feasible for the perioperative treatment of patients with gastric cancer,
meanwhile it could reduce the surgical stress, shorten the duration of hospital stay and improve QOL and
postoperative complications.
Keywords: ERAS, Surgical Stress, postoperative complications

P616
Safely Discharging Patients After Colonoscopy: An Evaluation
of the Modified Aldrete Score
Bradley Evans, BSc, Hons, MD1, M Borgaonkar, MD, FRCPC1, D
Pace, MD, FRCSC1, N Hickey, BSc, MD2, J McGrath, MD, FRCPC1,
1
Memorial University of Newfoundland, 2Dalhousie University

\0.001

* Median (Interquartile range 2575); N (%), Mean standard deviation; Currency on September 23, 2015

P614
Increased Blood Loss and Extended Postoperative Length of Stay
After Open Prostatectomy Compared to Robotic-Assisted
Prostatectomy
Steven Groene, MD, Davis Heniford, James Mark, MD, Tanushree
Prasad, MA, Amy Lincourt, PhD, MBA, Vedra Augenstein, MD,
Brent Matthews, MD, Carolinas Medical Center
Introduction: The aim of this study was to compare perioperative outcomes and operative supply costs
between open prostatectomy (OP) and robotic-assisted prostatectomy (RAP).
Methods: A precise random sample, representative of the 2014 OP and RAP patient population at a single
institution was generated and analyzed. Demographics, operative details and post-operative outcomes were
evaluated using standard statistical methods.
Results: Forty patients who underwent OP and 40 RAP were selected. There were no significant differences
in age, BMI, race, diabetes, COPD, CAD, hypertension, smoking, previous surgical history or tumor size.
Patients in the OP group were less likely to have prostate cancer (70 % vs 97.5 %;p = 0.002), had shorter
OR time (127.1 51.1 vs 188.5 48.4 min; p \ 0.001), and had more intra-operative blood loss
(519.4 318.8 vs 226.9 537.8 ml;p \ 0.001), but did not require more blood transfusions. While total
operative supply cost for OPs was less than RAP ($497 vs $3103; p \ 0.001), the OPs were associated with
a significantly longer LOS (3.0 2.1 vs 1.7 0.7 days; p \ 0.001). With an average follow up of
7.4 4.5 months between the groups, there were no significant differences in post-operative infectious
complications, DVT, clinically significant incontinence requiring intervention, potency, cardiac events,
bleeding, incisional hernias, readmissions, unplanned returns to the OR or mortality.
Conclusions: Patients undergoing OPs had similar demographics and pre-operative characteristics as those
undergoing RAPs, other than that patients undergoing RAP were more likely to have cancer. OP was
associated with more intra-operative blood loss, shorter operative time but a longer LOS compared to RAPs.
Otherwise, post-operative outcomes were similar between the groups.

Purpose: To investigate safety of the modified Aldrete scoring system as a tool to evaluate readiness for
discharge after colonoscopy.
Methods: This retrospective cohort study was performed on adults who underwent colonoscopy in the city
of St. Johns, Canada, in the year 2012. Subjects were identified through records from the health authority.
Data were extracted from the electronic medical record, including both the endoscopist and nursing procedure reports. Data were recorded on a standardized data sheet and entered into SPSS version 20.0 for
analysis. Modified Aldrete score upon discharge was recorded by endoscopy nursing staff. A score C 9 was
considered safe for discharge. Type and amount of sedation was recorded during the procedure. Perioperative adverse events occurred before discharge from the endoscopy unit and included; hypotension (\90/50
or\20 % baseline), hypoxia (SpO2 \ 85 %), allergy, use of reversal agents, or need for CPR. Late adverse
events were recorded within 14 days of discharge and included; transfer to emergency room, unplanned
hospitalization or unplanned contact with health professional.
Results: Data were collected on 3235 colonoscopy procedures. Mean patient age was 58.4 years with
55.8 % of the group being female. Most patients (97.1 %) were outpatients and were ASA class 1 or 2
(73.5 %). Asymptomatic screening or surveillance was the most common indication (61.3 %). The majority
of patients received some form of sedation (98.1 %). The most commonly used sedatives were fentanyl
(mean dose 94.22mcg) and versed (mean dose 3.09 mg). Aldrete score at discharge was recorded for 2515
patients and of those, 98.9 % had a score C 9 on discharge.
Hypotension and hypoxia occurred in 15.4 % and 9.9 % of patients, respectively. Reversal agents were used
in 4 patients to treat hypoxia and hypotension. There were 4 deaths recorded within 30 days of the procedure, none of which were felt to be sedation related. Late sedation related adverse events occurred in 10
patients. 9 of the 10 patients had an Aldrete score C 9 and 1 was not recorded. Possible late sedation related
adverse events included; 2 patients with non-cardiac chest pain, 3 patients with benign abdominal pain, 2
falls, 1 patient with syncope and sinus bradycardia, 1 pneumonia, and 1 patient with decreased level of
consciousness.
Conclusion: Patients discharged with a modified Aldrete score of 9 or 10 had a 0.3 % incidence of delayed
adverse events that were possibly sedation related. This validates the practice of using a modified Aldrete
score of 9 or 10 to determine safe discharge post colonoscopy.

123

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Surg Endosc (2016) 30:S325S500

P617

P619

Preventable Electrolyte Disturbances and Anemia are Associated

with Increased Rates of Readmission Following Minimally
Invasive Esophagectomy

Predictors of Opioid Related Adverse Events in Open

and Laparoscopic Colorectal Surgery

Michelle C Nguyen, MD , Carl R Schmidt, MD, FACS , Robert E

Merritt, MD3, David S Strosberg, MD1, David B Renton, MD1, Lisa
Graham, MSN, RN, RNBC2, Kristen Johnson, MHA2, Susan D
Moffatt-Bruce, MD, PhD, FACS3, 1The Ohio State University
Wexner Medical Center, 2The James Cancer Hospital and Solove
Research Institute at The Ohio State University Wexner Medical
Center, 3Richard M. Ross Heart Hospital at The Ohio State University
Wexner Medical Center
Introduction: Patients undergoing esophagectomy have a high rate of unplanned postoperative readmission. With
reimbursements now linked to quality outcomes, hospital readmissions are being used as a surrogate indicator to gauge
patient outcomes. Our objective was to identify pre-discharge variables associated with readmission following minimally invasive esophagectomy to elucidate potential pre-discharge countermeasures aimed at decreasing
readmissions.
Methods and Procedures: Patients who underwent minimally invasive esophagectomy at the James Cancer Hospital
at Ohio State University Medical Center between 1/2012- 1/2014 were identified and patient medical records were
reviewed. Demographics, principle diagnosis, comorbidities, perioperative events, lab values at discharge, and 30-day
readmission rate were collected. Fishers exact test and Kruskal-Wallis test were performed with the above variables to
evaluate for statistically significant risk factors for unplanned hospital readmission.
Results: 51 patients underwent minimally invasive esophagectomy during the study period. 12 (23.5 %) patients were
readmitted within 30 days of discharge. 50 % of readmitted patients had a diagnosis code for anemia during their
initial hospitalization. Readmitted patients had lower magnesium, potassium and phosphate levels and higher RBC
distribution levels at the time of discharge compared to non-readmitted patients (p = 0.051, 0.044, 0.027, 0.030
respectively). All other patient demographics, comorbidities, perioperative diagnoses and lab values were not statistically significant.
Conclusions: In this patient review, hypomagnesemia, hypokalemia, hypophosphatemia and anemia were strong,
independently associated risk factors for increased rates of hospital readmission following minimally invasive
esophagectomy. Actionable pre-discharge targets need to be created and implemented to optimize patients prior to
discharge to reduce 30-day readmission.

Deborah S Keller, MS, MD1, David R Flum, MD, MPH, FACS2, Eric
M Haas, MD, FACS, FASCRS3, 1Colorectal Surgical Associates,
2
University of Washington, 3Colorectal Surgical Associates; Houston
Methodist Hospital; University of Texas Medical Center at Houston
Background: Opioids remain a mainstay of postsurgical pain control despite the potential impact of opioid related
adverse events (ORAEs) on patient outcomes and resource utilization. Our goal was to evaluate the incidence,
predictors, and impact of ORAE in patients who underwent colorectal surgery.
Methods: The Premier Perspective national inpatient database was reviewed for patients undergoing a colorectal
resection from 7/201311/2014. Patients were stratified into laparoscopic or open cohorts. The outcome measures
were the incidence of ORAE (identified by ICD-9 diagnosis codes), opioid consumption (identified from charges),
total hospital costs (estimated from cost to charge ratios), and resource utilization in patients with/without an ORAE.
Multivariate logistic regression was used to evaluate factors associated with ORAEs in open and laparoscopic colorectal surgery.
Results: 35,008 patients were evaluated- 18,779 open and 16,229 laparoscopic. Median opioid consumption was
446 mg (inter-quartile range, 217.5900) in the open group and 272 mg (inter-quartile range, 126611) in the
laparoscopic group. 26.2 % of open and 24.7 % of laparoscopic patients had a patient controlled analgesia for pain
control. Rates of ORAE were 19.8 % and 17.6 % in the open and laparoscopic cohorts, respectively. The most
common ORAE was ileus (10.9 % open, 10.1 % laparoscopic). The regression model found patients consuming
[300 mg of opiates, age [65, males, comorbidities of primary malignancy and chronic obstructive pulmonary
disease, and undergoing abdominoperineal resection were associated with higher likelihood of ORAE in both open and
laparoscopic cohorts. In the open procedure group, additional predictors included presence of congestive heart failure,
obesity, chronic pain, and urgent/emergent cases. In the laparoscopic group, additional predictors included chronic
renal failure and a total abdominal colectomy. On an unadjusted basis, patients who experienced an ORAE had
significantly longer length of stay (9.8 vs. 10.8 days, p \ 0.01 open; 5.4 vs. 8.2 days, p \ 0.01 laparoscopic), higher
mortality (2.9 % vs. 3.9 %, p \ 0.01 open; 0.31 % vs. 1.2 %, p \ 0.01 laparoscopic), and higher hospitalization costs
($21,459 vs. $24,712, p \ 0.01 open; $14,928 vs. $20,318, p \ 0.01 laparoscopic).
Conclusions: Currently, nearly 20 % of patients undergoing open and laparoscopic colorectal surgery experience an
ORAE. ORAEs carry a significant clinical and financial burden, potentially increasing length of stay, costs, and
mortality rate. This study found level of opiate consumption, age, gender, and comorbidities to be predictive of an
ORAE. With ORAE incidence and predictors identified, preemptive measures can be taken to improve postoperative
recovery and resource utilization.

P618
Laparoscopic-Assisted Peritoneal Dialysis Catheter Placement
Remains a More Expensive Method Of Placing A Catheter
Christopher Crawford, MD, Daniel Lomelin, MPH, Bradley Hall,
MD, Vishal Kothari, MD, University of Nebraska Medical Center
Introduction: Peritoneal dialysis (PD) catheters are utilized worldwide for patients with end-stage renal disease, but
usage is plagued with complications including inability to drain or catheter occlusion. Use of laparoscopy to facilitate
placement has been found to improve the rates of primary function as well as salvage of existing catheters. This
improvement in outcomes has previously been associated with an increase in the cost of the operation, raising the
question of whether it is more economical to place a catheter with open technique, even if it requires subsequent
revision versus placing it laparoscopically at the outset.
Methods: Records were obtained from the University HealthSystem Consortiums (UHC) Clinical Database/Resource
Manager tool from December 2011 to June 2015. UHCs database represents the majority of nonprofit academic
medical centers and affiliated hospitals in the USA. Records were selected as those patients 19 + years old with the
International Classification of Diseases9th revision (ICD-9) codes for chronic kidney disease, as well as procedure
codes for laparoscopic (54.98 and 54.21) or open PD catheter placement (54.98, excluding those with laparoscopy
code: 54.21). Direct cost, length of stay (LOS), demographics, and complication rates were reviewed. Statistical
analysis was conducted using SPSS v20.0.0.0. Median tests were utilized for cost to better account for skew.
Results: Selection criteria identified a total of 22,364 open PD catheters and 157 laparoscopic PD catheters among
inpatient cases. Median cost for open PD catheter placement was $10,371 (IQR: 7,35715,226), compared to $12,741
(7,755.7523,176.75) for laparoscopic PD catheter placement, (p \ 0.001).
Within inpatients, mortality rates (open: 3.44 %, lap: 2.55 %) did not significantly differ. However, the open operations had significantly higher patient disease severity (68.51 % major/extreme) compared to the laparoscopic group
(65.61 %, p = 0.001). The LOS was shorter in the open group (open: 5 days, lap: 6 days, p = 0.003), and the
complication rate was lower in the open group (open 10.10 %, lap: 17.18 %, p = 0.003).
Conclusion: The use of laparoscopy in PD catheter placement has been found to have better primary patency and
salvage rates, but its cost has been a limiting factor in recommending its use. This data registry review confirmed that
laparoscopy remains significantly more expensive. For patients with good physiologic reserve, the trade-off with
increased cost may be worth the improved patency. Patients with a laparoscopic PD catheter had lower disease severity
than the open group, which may be secondary to the fact that very ill patients may not tolerate laparoscopy.

123

P620
Impact of Obesity on Cholecystectomy Surgery
Christopher J Neylan, BA, Daniel T Dempsey, MD, MBA, Kenneth
Lee, MD, PhD, Rachel R Kelz, MD, Noel N Williams, MD, Kristoffel
R Dumon, MD, Hospital of the University of Pennsylvania
Objective: Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder disease. However, little
is known about the impact of obesity on cholecystectomy for acute cholecystitis. Few have compared laparoscopic
converted to open (LCO) and open cholecystectomies in the obese. This study intended to provide a comprehensive
analysis of the impact of BMI on cholecystectomy for acute cholecystitis.
Methods: Patients who underwent a cholecystectomy (laparoscopic, open, or converted) for acute cholecystitis from
20072013 were identified from the American College of Surgeons NSQIP database. Patients were classified into
normal (BMI 18.525), overweight (BMI 2530), obese (BMI 3035), severely obese (BMI 3540), morbidly obese
(BMI 4050), and super-obese (BMI 50 +) groups. The primary outcome was morbidity. Secondary outcomes were
mortality, prolonged operative time (procedure-specific operative time C 90th percentile), and prolonged post-operative length of stay (procedure-specific post-operative length of stay C 90th percentile). Independent multivariable
regressions were used to examine the association between BMI and the outcomes of interest.
Results: Of 23,284 patients included in the study, 46 % were obese (BMI C 30). Approximately 80 % of patients
underwent laparoscopic treatment, and this remained constant across the BMI groups. Among laparoscopic patients,
those with BMI C 30 had a significantly prolonged operative time (OR 1.24, p = 0.019), relative to the normal BMI
group (BMI 18.525). Among open patients, those with BMI C 30 had a significantly higher morbidity rate (OR 1.38,
p = 0.015), relative to the normal BMI group. Severe (OR 1.47, p = 0.02), morbid (OR 1.68, p = 0.01), and super
(OR 2.01, p = 0.03) obesity were significant predictors of LCO. Further, LCO operative time was significantly greater
than open operative time in all BMI groups except the normal weight group. Despite this, there were no significant
differences between LCO and open outcomes in any BMI group. The sole exception was a significantly increased
mortality among severely obese LCO patients. However, due to the small number of severely obese patients who died
(3 in LCO vs. 2 in open), this does not appear clinically significant.
Conclusions: The data suggest that standard treatment for acute cholecystitis should not be altered based on BMI, as
BMI has a limited impact on outcomes after both laparoscopic and open surgery. Further, laparoscopic surgery should
be attempted, even for very high (morbid and super-obese) BMI-patients. Despite an increased risk of conversion
among high-BMI patients, LCO outcomes are not worse than open outcomes.

Surg Endosc (2016) 30:S325S500

S487

P621

P624

Laparoscopic and Converted Approach Benefits Patients

in Complicated Diverticulitis

Robotic Assisted General Surgery: Really Cost Prohibitive?

Trevor Teetor, MD, Ted Bell, MS, Rod Grim, PhD, Vanita Ahuja,
MD, MPH, WellSpan York Hospital
Introduction: There is an increasing trend towards laparoscopic Hartmanns procedure versus standard laparotomy in
patients with complicated diverticulitis (abscess and perforation). No major study has reviewed performance measures
and results in order to better identify trends, assist in patient selection, and lead to improvement in morbidity and
mortality. The study examines outcomes including length of stay, complications, mortality and charges of complicated
diverticulitis by different operative approaches.
Methods and Procedures: A total of 16,043 cases were captured between 2009 and 2011 from HCUP-NIS data on
patients identified as complicated (abscess or perforated) Hartmann procedure. Variables under consideration included
patient age, gender, race, payment method, and Charlson comorbidity index. Hospital factors included size, location,
and teaching status. Outcomes included complications, median LOS, median charges, and mortality. These were
examined for open Hartmanns (OH), laparoscopic Hartmanns (LH), and procedures requiring conversion to open
(CH).
Results: Identified total 16,043: OH 14,665 (91.4 %): LH 832 (5.2 %), CH 546 (3.4 %). LH (20 %) and CH (23.4 %)
had lower complications than OH (27.3 %, p \ 0.001). Median age for each group is presented in Table 1. Also, LH
and CH (10 and 10 days, respectively) had significantly shorter LOS than OH (11 days) (p \ 0.001). While not
statistically significant, CH had lower charges ($69,675) than LH ($81,624) and OH ($72,795, P = 0.975). CH had
lower mortality rate (.9 %) than OH (3.5 %) and LH (1 %, p \ 0.001). None of the surgery groups were predictive of
complications or mortality. The predictors of complications included ages 60 + (OR 1.3), median income of $3545 K
(OR 1.3), Charlson score of 3 (OR 1.6), median hospital bed size (OR 1.2), Midwest hospital region (OR 1.2) and
elective admission (OR 1.4). Predictors of mortality included age 60 + (OR 2.7), Charlson 3 (OR 2.0), teaching
hospital (OR 1.7), West hospital region (OR 2.6) and complication (OR 2.5). LH surgery contributed $10,155 to total
charges.
Conclusions: Laparoscopic approach for complicated diverticulitis remains low, however LH and even CH approach
benefits patients over open methodology. Converted approach had slightly higher complication than laparoscopic but
lowest charges and mortality. Surgeons attempting LH should consider CH for (difficult, cases with high intraoperative
time) cases as this has shown to be beneficial for patient outcomes.

Table 1

Median characteristics by difference operative approach for complicated Hartmanns surgery

Introduction: Robotic assisted general surgery procedures have increased annually since 2011. Although the
advanced technical capabilities inherent to the robotic approach provide many surgical advantages, it is still not
perceived to be as cost effective as laparoscopic procedures. Continually improving intraoperative efficiency and
streamlined usage of robotic instrumentation may reduce the operative costs associated with robotics. A direct caseby-case comparison shows that robotic assisted procedures are comparable and/or more cost effective than their
laparoscopic counterparts.
Methods: Operative costs for individual robotic assisted procedures performed by two surgeons at a single institution
were reviewed during a one year period (June 2014June 2015); including single site and multiport cholecystectomy
(n = 100), inguinal hernia (n = 100), uncomplicated ventral hernia (n = 100), appendectomy (n = 20). Operative
costs for laparoscopic procedures performed by three surgeons at a single institution were reviewed during a three year
period (January 2009 January 2012); single site and multiport cholecystectomy (n = 100), inguinal hernia (n = 25),
uncomplicated ventral hernia (n = 50), appendectomy (n = 25). Operative costs were defined as surgical instrumentation specific to either a robotic assisted or laparoscopic approach.
Results:

Procedure

Robotic

Laparoscopic

Single Site Cholecystectomy

$648

$674

Multi-port Cholecystectomy

$484

$550

Uncomplicated Ventral Hernia

$1140

$1400

Inguinal Hernia

$1130

$1827

Conclusion: The operative costs of select robotic general surgical procedures compared to identical laparoscopic
procedures are equivalent and/or more cost effective. When reviewed on a case-by-case basis, it appears that the
enhanced technical capabilities inherent to the robotic approach may reduce the volume of instrumentation utilized in
comparison to laparoscopic.

P625

P622
A Single Institutions First 100 Patients Undergoing Laparoscopic
Heller Myotomy: Do Long-Term Outcomes Justify Continued
Application?
Alexander S Rosemurgy, MD, Janelle Spence, BS, Darrell J Downs,
ATC, Mark Giorgi, Christian B Rodriguez, BS, Indraneil Mukherjee,
MD, Sharona B Ross, MD, Florida Hospital Tampa
Introduction: This study was undertaken to report long-term outcomes after laparoscopic Heller myotomies performed more than 15 years ago to determine if outcomes are salutary and durable, and support continued application
of laparoscopic Heller myotomy as first-line therapy for achalasia.
Methods: With IRB approval, patients have been prospectively followed after Heller myotomy. Patients scored the
frequency and severity of symptoms using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Pre- and post-operative outcomes with Heller myotomy are compared. Data are presented as median or median
(mean SD), where appropriate.
Results: 100 patients (55 % men, age 48 years, BMI 24 kg/m2) underwent laparoscopic Heller myotomy prior to
2000. For all patients, follow-up is 10 years (10 5.3); with myotomy, dysphagia frequency fell from 10 (9 2.1) to
4 (4 2.8) and dysphagia severity fell from 10 (9 2.4) to 2 (3 2.9) (p \ 0.001 for each) without the development
of reflux related symptoms (e.g., heartburn) (Table 1). 29 patients were followed to death 7 years (7 4.4) after
Heller myotomy undertaken at age 71 years (69 12.7), 55 patients are currently lost to follow-up after follow-up
of 9 years (8 4.03), and 16 patients are currently followed at 17 years (17 1.1). Duration of follow-up did not
impact the frequency or severity of symptoms (Table 1). 83 % of patients are satisfied or very satisfied and 89 %
would have the operation again, knowing what they now know.
Conclusions: Long-term follow-up after laparoscopic Heller myotomy documents patient satisfaction and durable
symptomatic relief without troublesome new symptoms. Durable salutary benefits after laparoscopic Heller myotomy
justify its continued application as first-line therapy for achalasia.

Table 1

Wanda M Good, DO, Jason Cundiff, MD, Sherri L Finn, Alainna

Simpson, Pacific Northwest University of Health Sciences

Robotic Proctectomy for Rectal Cancer: Analysis Of 71 Patients

from a Single Institution
Philip M Spanheimer, MD1, John G Armstrong, MD1,
Sunyang Fu, BBA1, Junlin Liao, PhD1, Scott E Regenbogen, MD2,
John C Byrn, MD1, 1University of Iowa, 2University of Michigan
Background: Despite increasing use of robotic surgery for rectal cancer, reported outcomes have come from highly
specialized units and few series have been published from the practice of generalizable US surgeons. Thus, the effect
of formal robotic training and learning curves among early cases have not been well studied. We sought to critically
evaluate the short- and long-term outcomes of robotic rectal cancer resections by a single colorectal surgeon, selftaught after completion of formal training, in an academic institution without a specialized robotics focus.
Methods: We performed a retrospective chart review for the initial 71 consecutive patients who underwent robotic
low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010 and 2014.
Demographic, clinicopathologic, and intraoperative and postoperative outcomes data were abstracted from the medical
record using a standardized data collection tool. Total mesorectal excision integrity was graded by pathologists in 39
cases (55 %).
Results: We identified 46 LARs (65 %) and 25 APRs (35 %). Fifty patients (70 %) received preoperative
chemoradiation. Median procedure time was 219 minutes (IQR 184275), mean blood loss 165 cc (SD 156 cc), and
median length of stay 6 days (IQR 48). Radial margin was negative in all 46 LAR patients and 24/25 APR (96 %)
patients. Total mesorectal excision integrity was complete/near complete in 23/23 (100 %) graded LAR specimens and
15/16 (94 %) APR specimen. A mean of 16+/-8 lymph nodes were retrieved. There was one conversion to open, and
no perioperative blood transfusion or ureteral injuries. Within 30 days of surgery, we observed 4 (6 %) superficial and
5 (7 %) deep organ space infections and no urinary tract infections or deaths. At median follow up of 21.9 months,
there were no local recurrences. Five year disease free survival was 83.1 % and five year overall survival was 94.4 %.
Conclusions: Robotic proctectomy for rectal cancer was introduced in to a typical colorectal surgery practice by a
single surgeon. Over the first four years of experience, there was a low conversion rate, low complication rate, and
satisfactory oncologic outcomes. The role of patient selection, time trends, equipment changes, and training could not
be evaluated, yet these data highlight the need for broad improvements in the audit and feedback of surgical outcomes
for this rapidly-growing technology.

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P626

P628

Robotic Video Assisted Thoracoscopy: Minimally Invasive

Approach for Management of Mediastinal Tumors

Outcomes of Robotic-Assisted Versus Laparoscopic Repair

of Small Size Ventral Hernias

Pejman Radkani, MD, Devendra Joshi, MD, Tushar Barot, MD,

MPH, Roy Williams, MD, Mount Sinai Medical Center

Y. Julia Chen, MD, Desmond Huynh, BS, Kam Hei Tsuei, BA, MA,
Celia M Divino, MD, Edward Chin, MD, Scott Nguyen, MD, Linda
Zhang, MD, Mount Sinai Medical Center

Introduction: Tumors of the mediastinum represent a wide range of pathologic processes. Inspite of difficult anatomic access, surgical resection
remains the best diagnostic and therapeutic approach in the management of these rare tumors. Video assisted thoracoscopy (VATS) has been
developed as an alternative to open procedures but its widespread acceptance is restricted by the limiting nature of instruments and suboptimal
visualization. Robotic assisted minimally invasive surgery seems to hold most promise in remote, narrow anatomical regions such as the mediastinum. We present a single surgeons experience with robotic assisted video-thoracoscopy (RVATS) for the resection of mediastinal tumor over a
period of 4 years.
Methods: A prospective database of patients undergoing RVATS between years 20092013 for the management of mediastinal tumors was
maintained. After obtaining approval from Institutional Review Board (IRB) at Mount Sinai Medical center, a retrospective review of the data was
conducted. Age, gender, co-morbidities, length of surgery, estimated blood loss (EBL), length of ICU and hospital stay, early and late post-operative
complications, conversion to open technique, tumor recurrence rate, and follow up were reviewed. SPSS software was used for statistical analysis.
Results: Forty-eight patients underwent robotic assisted thoracosopic resection of mediastinal tumor which included 22 females (45.8 %) and 26
males (54.2 %). The mean age of patients was 54.19 years. One procedure (2.1 %) was converted to open secondary to locally invasive nature of
tumor, the rest of the procedures were completed using robotic assisted thoracoscopy as planned. The most common location of the tumor was
anterior mediastinum (69.4 %). The most common pathologic diagnosis was thymoma (16.7 %). The size of the mass ranged from 0.6 cm to
12.5 cm in greatest dimension (mean - 5.16 cm). The mean duration of procedure was 127.96 minutes (60 - 240 minutes). Average blood loss was
45.94 ml (5 - 500 ml). The mean hospital stay was 3.73 days. Five patients (10.4 %) had early postoperative complications including chylothorax (1
patient), new onset atrial fibrillation (1 patient), pleural effusion (1 patient) empyema (1 patient) and bleeding (1 patient). Mean follow up time was
186 days (10 - 1300 days). Two patients (4 %) with invasive thymoma developed local recurrence.
Conclusion: The present study documents the feasibility of RVATS in the management of mediastinal tumors irrespective of the location in various
mediastinal compartments. The role for careful and complete excision of the tumor, and surveillance afterward on invasive thymoma was noted in
our study, as in literature.

Introduction: The aim of the study is to investigate the outcomes of the da Vinci robotic-assisted laparoscopic hernia repair of small size ventral
hernias with circumferential suturing of the mesh compared to the traditional laparoscopic repair with trans-fascial suturing.
Methods and Procedures: A retrospective review was performed at our institution between 2013 and 2015 of all robotic-assisted umbilical,
epigastric, and incisional hernia repairs compared to laparoscopic umbilical or epigastric hernia repairs. Patient characteristics, operative details, and
postoperative complications were collected and analyzed using univariate analysis. Three primary minimally invasive fellowship trained surgeons
performed all of the procedures included in the analysis.
Results: 72 patients were identified during the study period. 39 patients underwent robotic-assisted repair (RR) (21 umbilical, 14 epigastric, 4
incisional) and 33 patients laparoscopic repair (LR) (27 umbilical, 6 epigastric). 7 were recurrent hernias (RR: 4, LR: 3). There were no significant
differences in preoperative characteristics between the two groups. Average operative time was 156 minutes for RR and 65 minutes for LR
(p \ 0.0001). The average defect size was significantly larger for the RR group [3.07 cm (19 cm)] than the LR group [2.02 cm (0.55 cm)],
(p \ 0.0001) although there was no significant difference in the average size of mesh used (13 cm vs. 13 cm). There was no difference in patients
requiring post-operative admission or length of stay between the two groups. The average duration of follow up was 21.7 days. There was no
difference in complication rate during this time and no recurrences were reported.
Conclusion: Small size ventral hernias repaired using the robotic-assisted technique demonstrates equivalent safety and efficacy when compared to
the standard laparoscopic hernia repair.

P627
Clinical Evaluation of Complete Solo-Surgery with the Robotic
Laparoscope Manipulator VIKY
M Takahashi, MD1, N Nishinari, MD1, H Matsuya1, M Takahashi,
MD2, T Tosha, MD2, Y Minagawa2, C Tono, MD2, T Yoshida2,
1
Morioka Yu-ai hospital, 2Iwate Prefectural Kuji Hospital
Introduction: Advancement in both surgical technique and medical equipment has enabled Solo-surgery. ViKY Endoscope Positioning System
(ViKY) is a robotic system that remotely controls an endoscope and provides direct vision control to the surgeon. Its voice control function offers
high degree of freedom to the surgeon. It does not move against the surgeons will, and keeps the endoscopic image fine and stable without shaking
even in longer cases; this makes Solo-surgery seem more feasible. Despite the increasing use of the transabdominal preperitoneal approach (TAPP)
in recent years, there are only a few reports of Solo-surgery with this approach. Here we report our experience with ViKY-assisted Solo-surgery.
Materials and Methods: ViKY, with its small-sized, computer-assisted motor, is an endoscopic holder that enables Solo-surgery. It can be easily
placed anywhere along the side rail of the operating table, and is designed to be extremely compact. Since July 2013, we retrospectively examined 17
cases of Solo-surgery TAPP with ViKY. ViKY was set-up by the surgeon alone, and the set-up duration was determined as the time at which the
side rail was positioned and that when the endoscope was installed. For assessing the control unit, the number of false movements was counted. We
statistically compared the operative results between ViKY-assisted Solo-surgery TAPP and the conventional method with an assistant.
Results: The average time to set-up ViKY was 9.1 minutes. The average number of orders given to ViKY during each operation was 99.1,
whereas the average number of false movements or the case that the control unit did not respond was 8.4. The average operative time was 140
minutes. No case required an assistant during the operation. The average postoperative hospital stay was 2.4 days. No statistical difference was
observed in the operative time and postoperative hospital stay between ViKY-assisted Solo-surgery TAPP and the conventional TAPP with an
assistant.
Conclusions: We evaluated ViKY-assisted Solo-surgery TAPP in a clinical set-up. ViKY proved reliable in recognizing orders with very few
failures, and the operations were performed safely and were comparable to the conventional operations with assistants. Because of the rapid reaction
of the endoscopic holder and the extremely clear vision that lasted for longer hours, the stress level was greatly reduced and, thus, the satisfaction of
the surgeon was very good. Solo-surgery can also be cost-effective as it does not require any specialized nurses and clinical engineers. Therefore,
Solo-surgery with ViKY seemed beneficial in this clinical evaluation.

P629
Safety of Robotic Thyroidectomy for Advanced Differentiated
Thyroid Carcinoma
Young Jun Chai1, Hyunsuk Suh2, Jung-Woo Woo3, Hyeong Won Yu3,
Ra-Yeong Song3, Hyungju Kwon3, Su-jin Kim3, June Young Choi4,
Seong Ho Yoo5, Kyu Eun Lee3, 1Department of Surgery, Seoul
National University Boramae Medical Center, 20 Boramae-ro 5-gil,
Dongjak-gu, Seoul, 2Department of Surgery, Mount Sinai Beth Israel
Hospital, Icahn School of Medicine at Mount Sinai, New York, USA,
3
Department of Surgery, Seoul National University Hospital
and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744,
Korea, 4Department of Surgery, Seoul National University Bundang
Hospital and College of Medicine, 300 Gumi-dong, Bundang-gu,
Seongnam, 463-707, Korea, 5Seoul National University Hospital,
Biomedical Research Institute and Institute of Forensic Medicine,
Seoul National University College of Medicine, Seoul, Republic
of Korea.
Introduction: The safety of robotic thyroidectomy (RT) has been well established for an early stage differentiated thyroid carcinoma and it is
generally indicated for the tumors B 2 cm. However, RTs have been selectively performed for the tumors larger than 2 cm when patients request or
the preoperative diagnosis of malignancy is uncertain. In this study, we evaluated the safety of RT by comparing the surgical outcomes of RT and
conventional open thyroidectomy (OT)
Methods: The medical records were retrospectively reviewed for the patients who underwent total thyroidectomy or hemithyroidectomy accompanied
by completion thyroidectomy due to the differentiated thyroid carcinoma from 2009 to 2014. The outcomes of surgery and radioactive iodine treatment
were compared between the patients who underwent RT and OT. As an RT procedure, bilateral axillo-breast approach (BABA) was used, and operations
were conducted by experienced endocrine surgeons.
Results: Totally 86 patients were eligible (21 BABA RT, 65 OT). Mean age was 30.8 for BABA RT group, and 51.6 for the OT group (p \ 0.001). The
mean tumor size were equal for both groups (2.8 0.6 cm, p = 0.991). Operation time was longer in the BABA RT group than in the OT group
(165.1 43.9 vs. 93.5 30.8 min, p \ 0.001). Vocal cord paralysis rate based on laryngoscopy evaluation were comparable for BABA and OT
(transient, BABA RT; 19.0 % vs. OT; 9.2 %, p = 0.250, permanent, 0 % vs. 1.5 %, p = 1.000). There was no significant difference in the postoperative
hypoparathyroidism rate (transient, BABA RT 19.0 % vs. OT; 33.8 %, p = 0.199, permanent, 0 % for both), and in the number of retrieved central
lymph nodes (BABA RT; 2.1 3.3 vs. OT; 1.5 1.9, p = 0.757). At initial radioactive iodine treatment, the proportion of the patients with stimulated
thyroglobulin (Tg) level of \ 1.0 ng/ml in the absence of anti-Tg antibody was 53.8 % (7/13) for BABA RT group and 65.3 % (32/49) for OT group
(p = 0.525). Neither group had recurrences during the median follow up period of 36.9 months for BABA and 25.5 months for OT.
Conclusion: BABA RT is a safe and oncologically sound treatment option for 24 cm differentiated thyroid carcinoma for a selected group of
patients. Its role in advanced thyroid carcinoma management should be continually evaluated as the RT experience and technology evolve.

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P630

P632

Early Experience with the Da Vinci Xi Surgical System

in Digestive Surgery

Nationwide Trends in Robotic General Surgery

Monika E Hagen, Minoa K Jung, Leo Buehler, Christian Toso, Jassim

Fakhro, Philippe Morel, University Hospital Geneva
Background: Robotic surgery has been developed to overcome some of the technical
limitations of conventional laparoscopy and improved by different version of the da Vinci
Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) over the past decades.
While previous models including the da Vinci Standard, the S and the Si Surgical System
have been successfully applied to a variety of procedures, continuous criticism has been
raised regarding a complex set-up and the limited ability to operate in multiple abdominal
quadrants, which might be a contributing factor in the currently limited use of robotic for
abdominal surgeries. The da Vinci Xi Surgical System is the latest addition to the family of
robotic systems for laparoscopy and was released in 2014. This system offers the same
basic characteristics of the previous models including 3D vision, articulated instruments
and software features, but also comes with an updated user-interface, re-designed robotic
arms that offer a wider range of motion, longer instruments, and other specific features that
are targeted to facilitate robotic set-up and multi-quadrant procedures.
Materials and Methods: Perioperative data of patients who underwent robotic surgery
with the da Vinci Xi system within our first 6 month of experience was prospectively
collected and analyzed.
Results: Between March and September 2015, 55 patients underwent da Vinci Xi digestive
surgery at our department. 46 foregut (41 Roux-en-Y gastric bypasses), 7 colorectal procedures (4 left- and 1 right-sided), 1 hepatic resection and 1 lymphadenectomy were
performed. Mean operating time was 235.3 (+/-96.1) minutes with 229.4 (+/-84.3) minutes
for gastric bypass procedures and 290.7 (+/-43.7) for colorectal procedures. Mean docking
time was 8.7 (+/-4.0) minutes with no significant differences for upper gastro-intestinal and
colorectal docking. The gastric bypass procedure was successfully transitioned from a
hybrid approach to a fully robotic approach and all colorectal procedures (Right colectomy,
sigmoid resection and low anterior resection) were finished with a single robotic docking
without re-arrangement of robotic arms. 1 intra-operative and no postoperative complications occurred. 1 procedure was converted to conventional laparoscopy and 1 patient was
re-operated due to a bleeding of the robotic stapling line of the remnant stomach of a gastric
bypass procedure.
Conclusions: The da Vinci Xi Surgical System appears to enable the augmentation of
robotic procedures for gastric bypass and colorectal surgery. Further research is needed to
clearly determine the role of the da Vinci Xi Surgical System for digestive surgery.

P631
Robotic Versus Laparoscopic Lymph Node Dissection
for Colorectal Cancer
David Lisle, Alodia Gabre-Kidan, Ravi Pasam, Daniel Feingold, P
Ravi Kiran, Steven Lee-Kong, Columbia University Medical Center
Purpose: Colorectal cancer is the third most common cancer in males and second in
females world wide with an incidence of 1.2 million new cases and 608,700 deaths in 2008.
There appears to be a positive correlation between number of lymph nodes resected and
survival in colon cancer. Minimally invasive colectomies are gaining acceptance and
laparoscopy is becoming standard treatment for elective colorectal resection. The field of
robotic surgery is, also growing and now extends to colorectal procedures. Few studies have
compared the effectiveness of lymph node sampling in robotic vs laparoscopic surgery in
colorectal cancer.
Methods: A restrospective review at NYP-Columbia medical Center EMR between
September 2012 and July 2014. We compared lymph node dissection in patients who
underwent robotic vs laparoscopic colorectal resection performed by the PI. The primary
endpoint included total number of sampled lymph nodes. Separate subgroup analysis
looking at right colon, sigmoid colon and rectal resections comparing primary endpoints
was also done.
Results: Between September 2012 and July 2014 the PI performed 51 colorectal resections
for malignancy. 31 patients had robotic resections and 25 underwent laparoscopic resection. The mean age at diagnosis of the laparoscopic group was 69 vs 59 in the robotic group
(t-value: -2.4; p-value 0.02). The groups were similar in gender (lap 56 % female vs
robotic 52 % female) and BMI (lap mean BMI: 28; robotic mean BMI; p-value: 0.73).
When looking at all colorectal surgeries, the mean number of lymph nodes sampled was
equivalent when comparing robotic versus laparoscopic approaches (28 vs 24; P = 0.31).
Similarly, in subgroup analysis looking at right colectomy, sigmoid colectomy and rectal
resection separately no difference in number of LNs sampled was found when comparing
laparoscopic vs robotic surgery.
Conclusion: Colorectal consensus guidelines recommend a minimum of 12 lymph node
sampling in order to accurately stage cancer. In addition, there is a survival benefit directly
correlating to the number of nodes sampled. In our experience both robotic and laparoscopic surgery meet and surpass the minimum standards for lymph node resection. Robotic
surgery appears to be a viable alternative to laparoscopy in regards to number of lymph
nodes sampled. Further randomized controlled trials are necessary in order to confirm these
results and to better understand how robotic vs laparoscopic lymph node sampling effects
recurrence and survival.

John N Afthinos, MD, Roman Grinberg, MD, Karen E Gibbs, MD,

Staten Island University Hospital
Introduction: Robotic assisted general surgery is gaining significant popularity among
clinicians and patients. There have been multiple single-surgeon and single-institution
studies demonstrating its safety and efficacy as a minimally invasive option. We sought to
evaluate trends in robotic assisted general surgery using a large national database.
Methods: The National Inpatient Sample database was queried for all adult, elective
abdominal surgeries from 2005 to 2011. We evaluated the most common robotic assisted
procedures. Patients undergoing elective robotic assisted procedures were evaluated for age,
gender, comorbid conditions and post-operative morbidity and mortality.
Results: During the study period 3,656,117 abdominal cases were identified, of which
35,212 were robotic assisted (1 %). The year 2011 accounted for 42 % (14,817) of all
robotic assisted surgeries. The average age of the study group was 51.5 + 13.7 years and
48 % were women. Overall post-operative morbidity was 7 % and mortality 0.4 %
(Table 1).
Conclusion: Robotic assisted general surgery procedures continue to experience growth.
Immediate post-operative outcomes appear to be in line with expected norms. Abdominal
wall hernia repairs are the most common robotic assisted general surgery procedures.

Table 1

The five most common robotic assisted procedure categories

P633
Robotic Single-Incision Cholecystectomy: A Retrospective Review
of a New Technique
Eugenia Kang, MD, Diane Kwan, MD, John Muir Medical Center
Introduction: Laparoscopic cholecystectomy has become the standard of care for
removing the gallbladder. This standard confers the well-known benefits of minimally
invasive surgery including less pain, faster recovery, and better cosmetic results. Traditional
technique uses four port sites. By utilizing the technology afforded by robotic cholecystectomy, one small incision hidden in the umbilicus is all that is needed to remove the
gallbladder as safely and effectively as laparoscopic cholecystectomy, with improved
cosmesis.
Technique: A 2.5 cm incision is made through the umbilicus to accommodate the singlesite port. Curved robotic instruments are inserted through the port and docked under direct
visualization of the robotic camera. The flexible, curved instruments allow triangulation in
the area of dissection, and achievement of the critical view of safety without requiring
multiple ports. The same techniques of dissection are utilized as in laparoscopic cholecystectomy, allowing dissection of the gallbladder off the liver bed, and removal through
the umbilical incision without any need to dilate or extend the port site.
Methods: We performed a retrospective analysis of a two-surgeon experience between
March 2014 and September 2015. The goal of the study was to evaluate operative times
over the learning curve of the robotic procedure, review complications, and validate this
technique as an alternative to the traditional laparoscopic procedure.
Results: 111 consecutive patients were studied. Four patients had conversion to multiport
robotic, laparoscopic or open cholecystectomy. Ten patients required additional time to
perform an intraoperative cholangiogram. A total of 14 patients were subsequently
excluded. Ages ranged from 17 to 84. 76 (78 %) were female; 21 (22 %) were male.
Average length of operation was 83 minutes (44140), which decreased with increasing
experience. Average length of hospital stay was 1.2 days (all outpatients were discharged
the day of surgery or after 23 hrs observation). 4/97 (4 %) had postoperative wound
infections that resolved with antibiotic treatment. Two patients (2 %) experienced port site
hernias.
Conclusion: Robotic-assisted single-incision cholecystectomy can be performed safely and
effectively with good outcomes and improved operative times. No patients were readmitted
with bile leak. Hernia formation risk is low. Infection risk is low. Trends in operative time
correlate with BMI and were increased in male patients and inpatient cases. There is no
difference in operative time with ASA. Operative times improve over time. Additional
prospective studies are needed to compare results between laparoscopic and robotic
techniques.

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P634

P635

Effect of Surgical Technique on Pain and Narcotic Use After

Robot-Assisted and Open Distal Pancreatectomy

Systematic Review of Robotic-Assisted Thymectomy and Metaanalysis of Robotic Versus Video-Assisted and Transsternal
Thymectomy for Myasthenia Gravis and Anterior Mediastinal
Masses

Ammara A Watkins, MD1, Sjors Klompmaker1, William E Gooding2,

Manuel Castillo-Angeles1, Yufei Liu, PhD1, Jennifer F Tseng, MD,
MPH1, Mark P Callery, MD1, Tara S Kent, MD1, A. James Moser,
MD1, 1Pancreas and Liver Institute, Beth Israel Deaconess Medical
Center and Harvard Medical School, 2Biostatistics Facility,
University of Pittsburg Cancer Institute
Introduction: Multiple studies demonstrate equivalent outcomes after robot-assisted distal
pancreatectomy (RADP) compared to open (ODP). Published data evaluating postoperative
quality of life after RADP are limited to surrogate markers such as length of stay. We
hypothesized patients undergoing RADP experience less postoperative treatment burden
relative to ODP as measured by pain scores and narcotic use.
Methods: Retrospective (July 2009March 2014) single-institution analysis of 010
numeric pain rating scale (NPS) and total morphine equivalents per 24 hours after distal
pancreatectomy through postoperative day (POD) #5. Laparoscopic distal pancreatectomy
was excluded due to limited volume. The ODP cohort comprised two groups due to
standard of care epidural analgesia: ODP with epidural (analyzed as intent to treat) and
ODP without epidural. The RADP cohort received parenteral narcotics alone. Marginal
regression analysis analyzed the effect of epidural analgesia on daily narcotic use.
Results: Of 117 patients, 84 had complete NPS and narcotic data. There were 50 patients
who underwent ODP with epidural, 11(18 %) underwent ODP without epidural and
23(27 %) underwent RADP. NPS resembled statistical noise and were uninformative (data
not shown). A mixed effects linear model for repeated measures was developed, validated,
and applied to daily mean pain scores and narcotic use to evaluate trends over time.
Differences evolved in a time-dependent manner consistent with recovery from a surgical
procedure. Predicted mean narcotic use was greatest on the day of surgery after ODP
without epidural compared to RADP and ODP with epidural (p \ 0.05, Fig. 1). On POD 1
and 2, narcotic use was greater after RADP or ODP without epidural compared to ODP with
epidural (p \ 0.05). By POD 34, all three groups had equivalent narcotic requirements. By
POD 5, narcotic use after RADP had decreased significantly and was equivalent to ODP
with epidural (p \ 0.05). Regression analysis indicated that epidural analgesia reduced
daily narcotic use by 28 % after ODP.
Conclusion: Over the six-day observation window, patients undergoing ODP with epidural
had the least narcotic use. Patients undergoing RADP require less narcotic than ODP
without epidural analgesia. Patients undergoing RADP had peaked narcotic use on POD
12 and demonstrated a rapid decrease in narcotic use by POD 5 compared to ODP without
epidural. We conclude that additional attention to pain management is required after RADP.
Epidural analgesia has a narcotic sparing effect but is not ideal for minimal-access surgery.
Patients undergoing RADP may benefit from regional analgesia in the immediate postoperative anesthesia to optimize their recovery.

Joshua Parreco, MD, Kandace Kichler, MD, Marcus Eby, MD,

Rennier Martinez, MD, Robert Scoma, MD, University of Miami
Introduction: Robotic-assisted thymectomy for the treatment of myasthenia gravis and
anterior mediastinal masses has been successfully reported around the world. The purpose
of this systematic review and meta-analysis was to evaluate and compare the results of the
robotic-assisted approach to the more traditional video-assisted or transsternal approaches.
Methods: Studies involving robotic-assisted thymectomy were systematically reviewed.
Studies comparing robotic-assisted thymectomy (RAT) to video-assisted thymectomy
(VAT) or transsternal thymectomy (TST) were included in the meta-analysis and analyzed
using random or fixed effect models to determine the mean difference or odds ratio.
Results: Twenty-three studies were identified and included 731 patients undergoing RAT.
This included 484 patients with myasthenia gravis and 216 patients with a thymoma. The
rate of conversion to open was 3.0 % with the most common reasons for conversion being
invasive thymoma (63.6 %) and desaturation (18.2 %). Complications occurred at a rate of
6.8 % with the most frequent complications being myasthenic crisis (20.0 %) and pleural
effusion (10.0 %). Eight studies were included in the meta-analysis for a total of 211
patients undergoing RAT. Three of these studies compared patients undergoing RAT to 164
patients undergoing VAT and five studies compared patients undergoing RAT to 152
patients undergoing TST. There were no significant differences in operative time between
RAT and TST [mean difference (MD) -12.60; 95 % confidence interval (CI) -97.43 to
72.22 min; p = 0.77] or between RAT and VAT [MD 0.92; 95 % CI -19.86 to 21.70;
p = 0.93]. A shorter hospital stay was found for patients undergoing RAT versus TST [MD
-4.09; 95 % CI -5.92 to -2.26 days; p \ 0.01]. However, there was no difference in
hospital stay when comparing RAT to VAT [MD -1.51; 95 % CI -4.45 to 1.43 days;
p = 0.32]. TST was associated with more postoperative complications than RAT [odds
ratio (OR) 0.30; 95 % CI 0.13 to 0.69; p \ 0.01]. When comparing RAT to VAT there was
no difference in postoperative complications [OR 1.43; 95 % CI 0.51 to 3.96; p = 0.49] or
conversion to open [OR 0.67; 95 % CI 0.09 to 5.19; p = 0.70].
Conclusions: RAT did not appear to add a significant amount of operative time compared
to VAT or TST. However, patients undergoing RAT had a decreased length of stay and
lower complication rates compared to TST. There was no difference in hospital stay,
complication or conversion rates compared to VAT (Fig. 1).

Fig. 1 Morbidity, robotic-assisted versus transsternal thymectomy

Fig. 1 Trends in predicted mean narcotic use during the postoperative period. * indicate that the group is
statistically different (p \ 0.05) from other groups on that postoperative day

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P638

Surgical Outcomes of Transaxillary Robotic Thyroidectomy

For Graves Disease: Comparison of Single-Incision And DoubleIncision

Incisional Hernias After Robotic Assisted Surgery

Eun Jeong Ban, Min Jhi Kim, JungBum Choi, Taehyung Kim, Seul Gi
Lee, Cho Rok Lee, Sang Wook Kang, Jandee Lee, Jong Ju Jeong,
Kee-Hyun Nam, Woong Youn Chung, Cheong Soo Park, Department
of Surgery, Yonsei University College of Medicine, Seoul, Korea
Background: This report details our experience with single-incision transaxillary robotic thyroidectomy (SITRT) for
Graves disease and provides a comparison to double-incision transaxillary robotic thyroidectomy (DITRT).
Methods: From June 2009 to June 2015, 26 patients who underwent transaxillary robotic thyroidectomy for Graves
disease were reviewed retrospectively. These patients included 18 individuals who underwent SITRT and 8 who
underwent DITRT. The clinical characteristics and surgical outcomes of the 2 groups were compared.
Results: The mean total operative time was 101.0 (88114) minutes for the SITRT and 158.5 (126191) minutes for
DITRT (P = 0.598). The mean weight of the resected glands was 91.5 (60123) g for the SITRT and 76 (33119) g
for DITRT (P = 0.468). The estimated blood loss was 17.5 (10150) mL for SITRT and 100 (5140) mL for DITRT
(P = 0.911). There was no significant difference in terms of preoperative thyroid function test and operation extent,
hospitalization period, and postoperative complications between two groups. There was no conversion to open surgery.
During a mean follow-up period of 14.78 9.29 months for SITRT, no patients continued antithyroid drugs or
developed recurrent GD. All patients who underwent SITRT were satisfied with the cosmetic outcomes.
Conclusion: Relative to DITRT, SITRT provides improved surgical outcomes with superior cosmesis. In comparison
to DITRT, SITRT is safe and feasible in the hands of an experienced robotic surgeon.

P637

Michael B Huck, MD, Myron Powell, MD, Stephen McNatt, MD,

Carl Westcott, MD, Adolfo Fernandez, MD, Wake Forest Baptist
Health
Proponents of robotic assisted surgery (RAS) argue that the rate of incisional hernia (IH) is lower than that of typical
laparoscopic surgery. Use of smaller port-incision sites and less direct tissue trauma because of robotic instrument
articulation have been used to support this assumption. To date, there have been only a handful of case reports
examining IH rates following RAS. It is possible that IHs after RAS are underappreciated. To investigate this
hypothesis, we examined our institutions experience with repairing IHs after RAS, and discuss these hernias in relation
to reported information about laparoscopic IHs.
We conducted a retrospective chart review of all patients that underwent robotic assisted surgery at our institution
between September 2012 and April 2015. These included surgeries within Urology, Gynecology, and General Surgery.
Primary outcome was incisional hernia requiring surgical repair within the Division of Minimally Invasive Surgery
(MIS). Secondary outcomes included patient characteristics at time of original surgery of BMI, Creatinine, hemoglobin A1c, albumin and smoking status as well as the site of hernia, and type of closure required. Other secondary
outcomes included length of stay of original surgery and at time or repair.
We identified 1,269 patients who underwent abdominal robotic assisted surgery at our institution between September
2012 and April 2015. Of these patients, 20 patients developed 21 symptomatic incisional hernias resulting in an
incidence of 1.65 %. Of the 21 IHs repaired, 14 occurred at extraction sites, and 7 occurred at port sites. Of the 7 IHs
that occurred at port sites, 4/7 occurred at 8 mm port sites, and 3/7 occurred at 12 mm port sites. Fascia of the 12 mm
port sites, and extraction sites were closed, but not the 8 mm sites. The fascia of extraction sites were closed during
original surgery. Fascial defect at time of repair ranged from 1 cm to 5 cm, with average size 2.1 cm in greatest
dimension. 1/7 where repaired in open technique, 6/7 were repaired laparoscopically.
Our results show that IHs are possible after RAS, even at sites away from the specimen extraction site or camera port.
Our incidence for IHs are in line with previously published data and infer no protective effect for IHs inherent to
robotic surgery. Our study is limited with respect to small numbers, and that only patients who underwent repair within
our Department of MIS are included. RAS is not safer than laparoscopic surgery in relation to post-operative IH
formation.

A Retrospective Comparison of Robotic Cholecystectomy Versus

Laparoscopic Cholecystectomy: Operative Outcomes and Cost
Analysis

P639

David S Strosberg, MD1, Michelle C Nguyen, MD1, Peter Muscarella

II, MD2, Vimal K Narula, MD1, 1The Ohio State University Wexner
Medical Center, 2Montefiore Medical Center

Use of Indocyanine Green Fluorescence for Parathyroid Glands

Preservation in Bilateral Axillo-Breast Approach Robotic
Thyroidectomy

Introduction: Robotic-assisted surgery is gaining popularity in general surgery. The cost-effectiveness of robotic
surgery has been elucidated, however the cost-outcome association has yet to be determined. Our objective was to
evaluate and compare operative outcomes and direct costs for robotic cholecystectomy (RC) and laparoscopic
cholecystectomy (LC).
Methods and Procedures: A retrospective review was performed for all patients who underwent single-procedure RC
and LC from January 2011 to July 2015 at a large single institution medical center. Demographics, comorbidities,
diagnosis, use of cholangiography, conversion to an open procedure, bile duct injury, blood loss, length of surgery and
hospital stay, 60-day readmissions, post-operative complications, need for reoperation, and operative and hospital
costs were collected and analyzed between those patients groups. Statistical significance was determined using
Students t-test or Fishers exact test.
Results: 272 patients underwent RC or LC during the study period; 256 patients underwent single procedure and
comprised the study population. 114 patients (44.5 %) underwent LC and 142 patients (55.5 %) underwent RC.
Patients who underwent RC had a higher body mass index (p = 0.0016), lower rates of coronary artery disease
(p = 0.0038), higher rates of preoperative symptomatic cholelithiasis (p = 0.0054) and chronic cholecystitis (0.0115),
and lower rates of acute cholecystitis (p \ 0.0001). There were lower rates of intraoperative cholangiography
(p = 0.0008), conversion to an open procedure (p = 0.0238), blood loss (p = 0.012), hospital stay (p = 0.0001), and
readmission (p = 0.033) for robotic cholecystectomy. Patients who underwent RC had longer operative times
(p = 0.0072). There were no bile duct injuries in either group, no difference in bile leak rates (p = 0.6311) or need for
reoperation (p = 1.000). There was no difference in total direct operative and hospital costs (p = 0.365).
Conclusions: Robotic cholecystectomy appears to be safe and cost neutral in comparison to laparoscopic cholecystectomy in a select patient population. Further studies are needed to understand the long-term implications of robotic
technology and its role in minimally invasive surgery (Table 1).

Table 1

Preoperative characteristics, operative outcome and cost analysis

Joon Woo Chung1, Joon-Hyop Lee1, Hyeong Won Yu2, Hyungju

Kwon2, Su-Jin Kim2, Young Jun Chai3, June Young Choi1, Seong Ho
Yoo2, Kyu Eun Lee2, 1Seoul National University Bundang Hospital,
2
Seoul National University Hospital, 3Seoul National University
Boramae Medical Center
Bilateral axillo-breast approach (BABA) robotic thyroidectomy has shown favorable cosmetic and surgical outcomes.
With increasing use of BABA robotic thyroidectomy, many efforts have been made to reduce complications related to
parathyroid glands and recurrent laryngeal nerves (RLNs). In this study, we focused on preservation of parathyroid by
indocyanine green (ICG) fluorescence under near-infrared (NIR) light.
From 2013.12 to 2015.5, among patients who had underwent BABA robotic thyroidectomy due to thyroid cancers, 13
patients were enrolled with informed consents. The patients were given 10 mg ICG intravenously after strap muscle
dissection. By NIR integrated scope (illuminator: 805 nm/filter: 825 nm), ICG was excited and emitted fluorescence.
Based on the time that fluorescence appeared and disappeared in thyroid and parathyroid, visualization durations with
optimal identification time were estimated, with an attempt to find RLNs. Simultaneous intraoperative PTH assays
were done for biochemical confirmation of parathyroid detected by ICG fluorescence. Patient demographics and
clinico-pathologic characteristics were analyzed together.
The elapsed time to thyroid and parathyroid visualization were 211 120(s) and 218 94(s) with fluorescence
duration of 17.6 2.6(min) and 20.8 6.0(min), respectively. In all cases we could distinguish parathyroid from
thyroid. Though earlier enhancement of thyroid, parathyroid showed more focal and intense fluorescence pattern.
RLNs didnt show ICG fluorescence in contrast to thyroid and parathyroid. PTH assay results suggested proper
parathyroid identification had been done in all patients. In postoperative period mild transient hypoparathyroidism was
reported in one patient, otherwise no recurrent RLN palsy occurred.
According to results of our study, parathyroid preservation using ICG fluorescence by NIR light is seemed to be
feasible and safe in BABA robotic thyroidectomy. RLNs were also easily detected and saved by means of its nonfluorescent property. More randomized-controlled studies will be needed to support our conclusion and promote its
application in practice.

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P642

Importance of Robotic Training Curriculum for the Surgical

Oncologist: Direct Correlation Between Robotic Training
and Current Use of Robotics

Monopolar Instruments Transfer Stray Energy During Robotic

Surgery

Federico Tozzi, Sinziana Dumitria, MD, MScEpi, Micheal White,

MD, Byrne Lee, MD, Leanne Goldstein, Gagandeep Singh, MD,
Yuman Fong, MD, Yanghee Woo, MD, City of Hope - National
Cancer Center
Introduction: More than 10,000 robotic assisted cases have been completed since the inception of the first
surgical robotic system at our National Comprehensive Cancer Center training hospital. The adoption of
robotic surgery has consequently exposed the surgical oncology trainees to this technology during fellowship training. We propose to understand the impact of robotic surgery exposure during training on the
current practice of past-fellows.
Methods: Participation in robotic operations by surgical oncology fellows was retrospectively analyzed
from the institutional robot database from 2003 to 2014. A Web-based questionnaire with volunteer participation was distributed electronically to surgical oncologists who trained at this institution. Categorical,
ordinal and continuous variable questions were created to obtain the current practice, level of exposure to
robotic training and the integration of this technology once in practice. Robotic exposure score was calculated for each participant. We used descriptive and inferential statistics to analyze and correlate the
responses to the database.
Results: The survey was completed by 83 % of the past-fellow. There is a direct correlation between intraining exposure and the future use of robotics (r = 0.9997). The exposure scores were significantly higher
among robot adopters vs. non-adopters (mean 17.0 vs 13.6, p = 0.05) according to the online survey. Of the
survey responders, 60 % adopted robotic technology in their current practice. The primary application is in
colorectal (38 %), pancreas (22 %), foregut (22 %), and liver (13 %) surgery. The in-training exposure was
in colorectal (38.5 %), gynecology (30.5 %) and thoracic surgery (20 %). Robot adopters were more likely
to perceive robotic surgery training during fellowship as adequate compared to their counterparts (Percentage agree 40 % vs 20 %. Z-score %: 57 % vs 80 %). Additionally, 60 % of robot adopters did not
pursued further training after completion of their fellowship.
Conclusions: Surgical robotic exposure during fellowship training has a significant positive impact on the
adoption of robotic technology once in practice. In addition to gastrointestinal operations, gynecology and
thoracic surgery also provided a substantial contribution to robotics training during fellowship. Even if the
fellowship robotic training was perceived as suboptimal by adopter and non-adopter, the majority of robot
adopters did not pursue further robotic training after completing fellowship. This study confirms the need to
develop a standardized curriculum in robotic surgery during fellowship that includes gynecology and
thoracic surgery tailored to the trainees interests and needs.

Douglas M Overbey, MD2, Edward L Jones, MD, MS1, Douglas

Hirth, MD2, Teresa S Jones, MD, MS1, Thomas N Robinson, MD,
MS1, 2University of Colorado, Department of Surgery, 1Denver
Veterans Affairs Hospital, Department of Surgery
Introduction: Stray energy transfer from monopolar instruments during laparoscopy can be potentially catastrophic.
Robotic surgery is increasing in popularity however the risk of stray energy transfer during robotic surgery is
unknown. The PURPOSE of this study was (1) to quantify stray energy transfer using robotic instrumentation, (2) to
determine strategies to minimize the transfer of energy, and (3) to compare robotic stray energy transfer to traditional
laparoscopy.
Methods and Procedures: In a laparoscopic trainer box, the monopolar instrument was activated using both robotic
instrumentation (da vinci system) and traditional laparoscopic instruments. In both set-ups, energy was delivered
through an L-hook. A camera telescope and assistant grasper were inserted into the trainer. During energy activation to
the L-hook, each nonelectrical instrument (camera and grasper) tips were placed adjacent to the simulated tissue. The
primary outcome variable was an increase in simulated tissue temperature (C) placed adjacent to the non-electrical
grasper and camera tips. Temperature was measured with a thermal camera.
Results: Simulated tissue increased in temperature nearest the tip of the robotic assistant port grasper (18.3 5.8C;
p = \0.001) but not nearest the robotic camera tip (2.3 3.6C; P = 0.08). Strategies to decrease energy transfer
included: using desiccation technique in preference to open-air activation (0.15 0.2 vs. 18.3 5.8C, p \ 0.001);
decreasing power setting from 30 Watts to 15 Watts (18.3 5.8 vs. 2.6 2.8, p \ 0.001); and using low voltage cut
mode in preference to coag mode (3.1 2.1 vs 18.3 5.8, p \ 0.001). When compared to traditional laparoscopy,
stray energy transfer to the grasper was not statistically different between robotic and laparoscopic instruments
(18.3 5.8 vs 16.9 6.6, p = 0.6). However, significantly more energy transferred to the laparoscopic camera tip
compared to the robotic camera tip (18.7 5.3 vs 2.3 3.6C, p \ 0.001).
Conclusions: Unintentional energy transfer occurs during robotic surgery. In contrast to traditional laparoscopy, the
assistant grasper is the highest risk for thermal injury due to stray energy transfer. Strategies to reduce stray energy
transfer in robotic surgery include avoiding activation without tissue contact, lowering generator power setting and
using low voltage cut mode in preference to coag mode. These practical findings can aid surgeons using the robotic
surgical approach to minimize inadvertent energy transfer.

P643
Robotic Assisted Cholecystectomy In The Complex, Comorbid
Population: Safer?

P641

Wanda M Good, DO, Jason Cundiff, MD, Sherri L Finn, Alainna

Simpson, Pacific Northwest University of Health Sciences

Robotic Single Site Cholecystectomy: MIS Fellowship Program

Experience with the First 135 Cases in a New York City
Community Medical Center

Introduction: The routine utilization of robotics in general surgery remains controversial, but may represent a better
approach for safer, cost effective cholecystectomy in complex patient populations. Laparoscopic cholecystectomy has
been the standard of care for biliary disease with well-established outcomes, but patients with morbid obesity, multiple
co-morbidities, complex abdominal surgical history and acute cholecystitis remain challenging populations with
potentially higher complication rates. The emergence of daVinci robotic technology with enhanced optics and wristed
instrumentation provides improved technical capability and may result in lower intraoperative complication rates and
conversion to open cholecystectomy.
Methods: From March 1, 2012 to August 30, 2015, a total of 503 patients underwent robotic assisted laparoscopic
cholecystectomy by two surgeons at a single institution. Most patients were identified as being morbidly obese
(BMI [ 35), with a history of major abdominal surgery, or suffering from acute cholecystitis. A retrospective review
was performed for these patients, noting the outcomes and complications of the procedure.
Results: Over 500 patients with a mean age of 54.9 10.0 years (range 1987). All patients were identified as
having at least one of the inclusion criteria delineated above. Mean preoperative body mass index (BMI) of
38.4 7.9 kg/m2 (range 24.880.4). 53 % of patients were categorized as having acute cholecystitis. 28 % of
patients had prior history of major abdominal surgery. The incidence of common duct injury was 0.0 %. One patient
had a bile leak (0.15 %) which was predicted after removal of a necrotic gallbladder extending to the cystic duct,
requiring postop ERCP with stent placement. Two patients required interventional drainage of an intraabdominal
abscess (0.39 %). Two patients required conversion to open cholecystectomy (0.39 %)
Conclusion: Robotic assisted cholecystectomy in a difficult patient population results in improved, cost-effective
patient outcomes. Laparoscopic cholecystectomy is the most common abdominal surgical procedure in the U.S. with
approximately 750,000 performed annually. Seemingly low statistical complication rates for bile leak, common bile
duct injury and conversion to open cholecystectomy still adversely affect thousands of individual patients annually.
The technical advantages conferred by the 3D Hi-definition visual system and endowrist instrumentation may allow
for better visualization, and therefore more precise means of performing cholecystectomy in challenging patients due
to morbid obesity, acute inflammatory state or dense intraabdominal adhesions.

Thomas J Shaknovsky, DO, Frederick Sabido, MD, FACS, Richmond

University Medical Center, Affiliate of Downstate Medical Center,
Department of Minimally Invasive Surgery
Introduction: In our practice and as part of our MIS fellowship program, we used the da Vinci robotic
single site platform for all patients needing a laparoscopic cholecystectomy for 15 consecutive months. The
purpose of this study is to document the experience, results and conclusions after performing the first 135
robotic single site cholecystectomies as part of an Advanced GI MIS fellowship teaching curriculum.
Methods and Procedures: From March 2014 to July 2015, all robotic single site cholecytectomies performed by the MIS fellowship program director with active participation by the MIS Fellow and general
surgical residents were retrospectively reviewed. All patients were randomized to a single group, regardless
of BMI, diagnosis, co-morbidities, age or ASA class. No exclusion criterion was employed. Age, ASA
(American Society of Anethesiologists), diagnosis, BMI, total operative time (docking and console time)
and complications (death, cystic duct leak, bleeding, incisional hernia, wound infection, conversion to open
procedure and common bile duct injury) were retrospectively analyzed. All cases performed with fluorescence firefly cholangiogram. The umbilical fascial incision was closed with 0-maxon suture in a ratio of 4:1
to the defect in running fashion. Patient follow up was at 1 week and 3 months from surgery.
Results: A total of 135 robotic single site cholecystectomies were performed at our institution over the
15 month time frame. Mean age was 53.1 years (range 2180) and mean BMI was 30 (range 1953). Mean
ASA was 2 (range 14) and mean total operative time was 69.75 minutes (range 40105 minutes). The
patient cohort diagnosis breakdown was 22 (16.3 %) with cholelithiasis, 19 (14.1 %) with acute cholecystitis, 88 (65.2 %) with chronic cholecystitis, 2 (1.4 %) with biliary dyskinesia and 4 (3 %) with
gallbladder polyps. Three (2 %) patients developed an incisional hernia which was successfully treated with
interval repair with mesh. There were no deaths, no conversions to an open procedure, no cystic duct leaks,
no bleeding complications, no wound infections, no re-admissions for urinary retention and most importantly no common bile duct injuries. All patients were discharged as an ambulatory procedure.
Conclusion: Robotic single site cholecystectomy is cosmetically superior and safe to perform on any patient
regardless of diagnosis, BMI, age and ASA at a teaching community medical center. Routine use of
fluorescence firefly cholangiogram virtually eliminates the risk of CBD injury. Closure technique of the
fascial defect with 0-maxon in a ratio of 4:1 in running fashion minimizes the risk of incisional hernia.

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P645

Robotic Trans-Abdominal Pre-Peritoneal Inguinal Hernia

Repair: Is There a Benefit?

Voice Change in Robotic Versus Open Thyroidectomy :

Preliminary Results

Salvatore Docimo, Jr., DO, Hayk Stepanyan, Josh S Winder, Randy S

Haluck, Jerome R Lyn-Sue, Penn State Hershey Medical Center

Ra-Yeong Song1, Jin Wook Yi1, Hyeong Won Yu1, Joon-Hyop Lee2,
Hyungju Kwon1, Su-jin Kim1, Young Jun Chai3, June Young Choi2,
Seong Ho Yoo4, Kyu Eun Lee1, 1Department of Surgery, Seoul
National University Hospital and College of Medicine, 101 Daehakro, Jongno-gu, Seoul, Korea, 2Department of Surgery, Seoul National
University Bundang Hospital and College of Medicine, 300 Gumidong, Bundang-gu, Seongnam, Korea, 3Department of Surgery, Seoul
National University Boramae Medical Center, 20 Boramae-ro 5-gil,
Donjak-gu, Seoul, Korea, 4Seoul National University Hospital,
Biomedical Research Institute of Forensic Medicine, Seoul National
University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul,
Korea

Introduction: Laparoscopic inguinal herniorrhaphy can be performed utilizing trans

abdominal pre peritoneal approach (TAPP) and the totally extra peritoneal approach (TEP).
These approaches offer similar operative times, post-operative pain, return to work and
hernia recurrence1. The TAPP herniorrhaphy may also performed with robotic assistance.
We describe our initial experience utilizing robotic (Da Vinci Surgical System Sunnyvale,
CA) TAPP inguinal herniorrhaphy versus laparoscopic TEP (LTEP) inguinal hernia repair.
Methods: A retrospective review from June 2014 to June 2015 was performed. The records
for all patients who underwent robotic TAPP (RTAPP) and LTEP at Penn State Hershey
Medical Center were reviewed. Operative time, complication rate, and length of stay were
determined. The average cost of each procedure was also compared.
Results: Forty patients were included in the study, 20 patients in both the RTAPP and 20 in
the LTEP group. The mean age in the robotic group (RG) was 56.6 years and the
laparoscopic group (LG) was 55.9 years (p = 0.5899). The mean BMI in the RG was
27.4 kg/m2 and mean BMI for the LG was 26.5 kg/m2 (p = 0.50894). The average operative time for the RG was 134 minutes compared to 64.3 minutes for the LG
(p = \0.00001). There was no statistical difference in average operative time between the
first 10 robotic patients (111 minutes) and second 10 robotic patient (134 minutes)
(p = 0.064621). The mean length of stay for the RTAPP was 12.9 hours and 9.2 for the
LTEP (p = 0.0762). There were no minor or major complications in either of the groups.
The average cost per case for RTAPP was $2,364 and $1,503 for LTEP. There were 2
patients in the RTAPP that would not have been considered for TEP repair. One patient
with a large incarcerated inguinal hernia and another patient with sliding hernia with the
urinary bladder in the inguino-scrotal region.
Conclusions: The improved dexterity and increased degrees of freedom that the Da Vinci
robotic system offers (Intuitive Surgical Sunnyvale, CA) did not decrease operative times in
our early experience. Although both groups offered similar outcomes, such as similar length
of stay and complication rates, the increased operative time and cost makes laparoscopic
TEP hernia repair the ideal operative method at this time. However, robotic hernia repair
will likely play a role in difficult cases. Further studies regarding focusing on postoperative
pain and recurrence rate in these complex difficult cases are required. A tailored approach
may be needed overall.

Introduction: Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) is

considered safe and effective for the treatment of benign and malignant thyroid diseases,
providing with excellent cosmetic outcomes. This study compares voice changes in patients
receiving the BABA RoT, to conventional open thyroidectomy (OT), with a focus on the
impact of superior laryngeal nerve (SLN) injury.
Methods: Of 358 patients who had undergone total thyroidectomy between February 2015
and June 2015, a total of 137 patients who had completed both preoperative and postoperative voice evaluation were included in the study. The voice evaluation protocol in our
institute includes a perceptual assessment through the GRBAS (grade, roughness, breathiness, asthenia, strain) scale; electroglottography (EGG) and acoustic analysis; the
aerodynamic analysis, and the voice range profile (VRP). Patients were also asked to fill out
a voice questionnaire that includes the voice handicap index-10 (VHI).
Results: 32 (23.4 %) patients underwent BABA RoT, and 105 received OT. Patients in the
BABA RoT group were younger than those in the OT group (39.56 10.32 years vs.
48.85 12.57, p \ 0.001). Both groups did not differ in gender, final pathologic diagnosis,
and tumor size. There were no significant differences in preoperative self-assessment score
(VAS), GRBAS, VHI-10 and VRP. There were significant decreases in VAS and VRP, and
increases in GRBAS and VHI-10 during evaluation performed two weeks postoperatively
in both groups. The amount of change was lower in BABA RoT patients, although with no
statistical significance: change in VAS, 17.97 19.46 vs. 23.86 23.07 (p = 0.193);
change in GRBAS, 1.44 1.48 vs. 1.69 1.98 (p = 0.514); change in VHI-10 score,
8.59 10.73 vs. 11.0 10.14 (p = 0.249); change in VRP, 82.90 99.94 vs.
116.51 128.87 (p = 0.178).
Conclusion: BABA RoT provides with a wide, symmetrical view of the bilateral thyroid
lobes, as well as a better view of structures surrounding the superior pole. This enables for a
clear visualization and safe dissection of the external branch of the superior laryngeal nerve
(EBSLN) in most cases. The objective assessment of change in voice, and especially VRP,
shows that BABA RoT can result in less voice impairment, with better preservation of the
EBSLN, compared to OT. These are results of short-term changes in voice after
thyroidectomy.

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P647

Robotic Single-Incision Cholecystectomy, Although a Feasible

and Safe Option, Dramatically Increases Operative Time When
Compared to Single-Incision Laparoscopic Cholecystectomy

Firefly Utiization in Robotic Cholecystectomy: Safer

for the Patient?

Maureen D Moore, MD, Jonathan Abelson, MD, Renee Tholey, MD,

Suraj Panjwani, MBBS, Rasa Zarnegar, MD, Cheguevara Afaneh,
MD, New York Presbyterian Hospital-Weill Cornell Medical Center
Introduction: Surgeon-specific outcomes data has compared standard laparoscopic versus single-incision laparoscopic cholecystectomies. The purpose of our study was to compare perioperative outcomes between single-incision
laparoscopic cholecystectomies (SILC) and robotic single-incision cholecystectomies (RSILC) in patients with biliary
disease.
Methods: We retrospectively reviewed 50 consecutive patients who underwent a SILC or RSILC for acute cholecystitis, biliary colic/symptomatic cholelithiasis, gallstone pancreatitis and gallbladder polyps. We compared the first
21 patients undergoing RSILC to the first 29 patient undergoing SILC from January 2010 to September 2015. A total
of two surgeons experienced in robotic surgery participated in the study. Preoperative variables included demographics, body mass index (BMI), ASA score, and abdominal surgical history. Surgical variables included number of
ports, total operative time, estimated blood loss (EBL), conversion data, morbidity and length of stay (LOS). Our
primary end-point was operative time. Our secondary end-points were morbidity and LOS.
Results: Preoperative parameters were not significantly different between the two groups except for age (Table 1).
Mean operative time was 51 % longer in RSILC when compared to SILC (120 32 mins versus 79 35 mins,
p B 0.0001). There were no significant differences in EBL, conversion rates, intraoperative, and post-operative
complication rates. There was one complication in the RSILC group and two occurred in the SILC group. One patient
in each group developed choledocholithiasis requiring re-admission and ERCP. The other complication was a surgical
site infection, which was treated with antibiotics. The rate of additional port placement was not significantly different.
Furthermore, LOS was not statistically significant (Table 2). There was a strong inverse correlation between
chronologic case number and operative time for SILC, (r2 = 0.15; P = 0.04) however not for RSILC (P = 0.19).
There was no difference in surgeon-specific operative times.
Conclusion: RSILC is both safe and feasible. However, given the significant difference in operative time compared to
SILC, the robotic platform may not be cost-effective for surgeons that can adopt single-incision laparoscopic surgery.
If unfamiliar with single-incision laparoscopic surgery, the robotic platform offers an additional tool in the surgeons
armamentarium (Fig. 1).

Fig. 1

The learning curves for robotic single incision cholecystectomy and single-incision laparoscopic cholecystectomy

Table 1

Preooperative data

Table 2

Operative data

123

Eric L DuBois, MD, Stan C Hewlett, MD, FACS, Baptist Health

System
Introduction: Robotic surgery has increasingly been adopted by general surgeons and
provides a viable safer option to surgeries traditionally performed laparoscopically. With
the increased costs of robotics, a benefit over laparoscopic surgery needs to be shown to
justify the increased costs. Patient safety is a practical justification for the increased costs of
robotics. With the advancements in robotics, new technology such as firefly can aid the
surgeon during surgery and provide information previously unavailable.
Methods and Procedures: A survey was created for general surgeons to fill out immediately following a robotic cholecystectomy with or without firefly. The survey collected
data regarding operative time, use of firefly including dosage, preoperative timing, and the
structures identified both before and after dissection with white light and with firefly. The
survey results were collected in a database for statistical analysis. The survey was predominately distributed to general surgeons in the southeast United States.
Results: Firefly consistently aided the surgeons in identification of critical structures both
before and after dissection. Surgeons consistently identified more structures with firefly as
well. A difference in operative time with and without firefly was not found to be statistically
significant. Overall, in all the cases submitted, surgeons felt that firefly made the operation
safer for the patient 78 % of the time.
Conclusions: Laparoscopic Cholecystectomy is one of the most common surgeries performed today. While Robotic Cholecystectomy will not replace it any time soon, it is
another tool in the surgeons armamentarium and with the aid of firefly makes it potentially
safer for the patient as well.

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P650

Concurrent Robotic-Assisted Laparoscopic Paraesophageal

Hiatal Hernia Repair with Fundoplication And Robotic-Assisted
Video-Thoracoscopic Right Upper Lobectomy for Lung Cancer

Davinci Single Incision Cholecystectomy: A Successful Rural

Based Practice Experience

Eric M Toloza, MD, PhD1, David M Straughan, MD2, Jonathan

Hernandez, MD2, Joseph R Garrett, ARNPC, MPH1, Maki
Yamamoto, MD2, Tannous Fakhry, MD2, Carla C Moodie, PAC1,
Kenneth L Meredith, MD1, 1Moffitt Cancer Center, 2University
of South Florida Morsani College of Medicine
Introduction: Stage-3A non-small cell lung cancer (NSCLC) is generally treated with
induction chemotherapy and radiation therapy (RT), followed by surgery. Paraesophageal
hiatal hernia complicated by gastric volvulus should be surgically repaired. We report the
first known robotic-assisted paraesophageal hiatal hernia repair concurrent with roboticassisted pulmonary lobectomy for lung cancer.
Case Report: A 64-year-old diabetic, with 160-pack-year tobacco history, had positronemission tomography and computerized tomography demonstrating 6.3-cm right upper lobe
(RUL) lung mass, with hilar and subcarinal lymphadenopathy, but no distant metastasis.
Needle biopsies of RUL lung mass and para-azygos lymph node (LN) each revealed CK7positive/TTF1-positive adenocarcinoma, confirming stage-3A NSCLC. Gastric volvulus,
complicating his paraesophageal hernia, was treated non-surgically but delayed induction
chemotherapy. He eventually underwent carboplatin/Taxol chemotherapy 9 7 weeks with
500-Gy RT, decreasing the right NSCLC to 5.4 cm. He then underwent laparoscopic
paraesophageal hernia reduction and hernia sac resection, with robotic-assisted laparoscopic crurapexy and Nissen fundoplication. Concurrently, he underwent robotic-assisted
video-thoracoscopic RUL lobectomy, with mediastinal LN dissection, and right middle and
right lower lobe wedge resections 9 3, performed in left lateral decubitus via 3 thoracoscopy ports. Total operative (skin-to-skin) time was 545 min, including 341 min for
paraesophageal hernia repair and 204 min for lung resection. Total intraoperative estimated
blood loss was 360 mL. Postoperative complications included pulmonary embolus on
postoperative day (POD)#3; atrial fibrillation with rapid ventricular rate on POD#5; dysphagia requiring repeated swallow evaluations and slow advancement to regular diet;
prolonged air leak; and enlarging right pneumothorax (PTX) after chest tube removal,
requiring CT-guided pleural pigtail catheter. Pathology revealed minimal residual poorlydifferentiated carcinoma, with therapy-related necrosis and fibrosis involving 99 % of 4-cm
tumor, and 0 of 13 interlobar, hilar, and mediastinal LNs demonstrating metastatic carcinoma. On POD#17, he was discharged with therapeutic subcutaneous dalteparin and pigtail
catheter, connected to Pneumostat valve and removed on POD#26. He was readmitted on
POD#32 for increasing dyspnea from recurrent right PTX requiring CT-guided pleural
pigtail catheter and bedside transcatheter doxycycline pleurodesis. Air leak resolved, and
pigtail catheter was removed on POD#37. Patient then underwent consolidation cisplatin/
Taxol chemotherapy, which was discontinued due to nausea, emesis, persistent diarrhea,
and prolonged arthralgias.
Discussion: Patients with comorbidities tolerate minimally invasive surgery better than
open surgery. Although our patients diabetes, 160-pk-yr tobacco history, and induction
chemotherapy and RT likely contributed to his complicated postoperative course, he successfully underwent the first reported concurrent robotic-assisted paraesophageal hernia
repair with Nissen fundoplication and robotic-assisted RUL lobectomy for lung cancer.

P649
Comparison of Robotic Versus Laparoscopic Revisional Bariatric
Surgery
James L Taggart, MD, Julio Teixeira, MD, Lenox Hill Hospital
Background: The population of patients with bariatric surgery is increasing. A number of
these patients are seeking revisional bariatric surgery (RBS). Robotic surgery has been used
as a tool to tackle these technically complex operations. Our study examines the outcomes
of robotic revisional bariatric surgery versus the traditional laparoscopic approach.
Methods: A prospective data base was utilized to analyze all patients from September,
2013 to September, 2015 who had revisional bariatric surgery. A total of 28 patients were
identified (11 robotic, 17 laparoscopic, 0 open). All the patients had a conversion to either a
robotic revisional roux-Y-gastric bypass (RRYGB) or laparoscopic revisional roux-Ygastric bypass (LRYGB). These charts were then reviewed retrospectively and the outcomes reported.
Results: In the RRYGB group there were two complications, both required endoscopic
dilation of a stricture at the gastro-jejunal anastamosis, compared to zero complications in
the laparoscopic group (18 % versus 0 %). The operative time for the RRYGB was significantly longer then the LRYGB (376 minutes versus 228 minutes; P = 0.003). The
number of hospital days was longer in the laparoscopic group, but did not reach statistical
significance (2.92 days versus 2.36 days; P = 0.3). There were no conversions to open
surgery.
Conclusions: Robotic revisional bariatric surgery is safe and effective, but comes at the
cost of longer operative times. In our study, the RRYGB procedure was on average 148
minutes longer, however, there was a tendency towards a shortened hospital stay. Further
study is needed with larger sample sizes to define superiority of either operative approach in
revisional bariatric surgery.

Sofiane El Djouzi, Sean McClamon, Poplar Regional Medical Center

Background: Da Vinci single-incision cholecystectomy (DSIC) experienced originlly a
good acceptance when the technique was introduced, but the approach has been labeled with
limitations such as high rate of incisional hernia and wound complications. This study aimed at
sharing our practice experince and updating the previousely published outcome parameters.
Method: Retrospective review of a prospectively collected data on da Vinci single incision
cholecystectomies. The cases were performed at a rural facility by a fellowship MIS trained
single surgeon. The three arm da Vinci Si platform was used. The access was created
through a 2 cm skin semi-circular umbilical incision and a 2 cm longitudinal fascial
incision. A five-lumen soft single incision port was used for docking the flexible instruments. Using absorbable braided suture material, several figures of eight stitches were
fashioned to close the fascia. Descriptive statistics were analyzed followed by a fivequestion quality of life phone survey.
Results: A total of 109 cases were collected of which 69 % were female. The age range was
17 to 84 years with a median BMI of 31 [15.5 - 54.7]. The patients ASA was II in 66 % and
higher in the rest of the sample. The median total OR time was 88 min [44220 min] with
EBL recorded as 100 cc in 4 patients and less than 25 cc in the rest. Two conversions to
laparoscopic cholecystectomy and one to open surgery were reported. A total of 8 cases of
liver cirrhosis were diagnosed with 97 % of pathology reports unveiling a wide spectrum of
chronic cholecystitis severity. The phone survey reached 61 % responders with a postoperative follow-up ranging: [322 months]. Full satisfaction was collected in 92 % of the
patients. The wound complications were: 2 cases of wound infections with one requiring
incision and drainage of MRSA abscess and one case of hematoma that necessitated hospital readmission. There were only 2 cases of documented incisional hernias with no
additional cases revealed through the survey.
Conclusion: In our experience, DCIS is widely accepted by patients with an excellent
overall satisfaction and only 2.7 % wound complications. The technique is safe in acute
cholecystitis and feasible in super obese patients. The fascia closure technique is likely the
key factor leading to the low incisional hernia rate of 2 %.

P651
Robotic-Assisted Colorectal Surgery in Obese Patients: A CaseMatched Series
Jeffrey N Harr, MD, MPH1, Samuel Luka, MD1, Aman Kankaria2,
YenYi Juo, MD, MPH1, Samir Agarwal, MD1, Vincent Obias, MD1,
1
The George Washington University, 2University of Maryland
College Park
Introduction: Laparoscopic colorectal surgeries in obese patients have higher conversions
to laparotomy and complications, including increased surgical site infections, operative
times, blood loss, and length of stay. Several advantages of robotic-assisted surgery have
been reported, and may decrease complications in higher risk obese patients. Therefore, this
study evaluates outcomes of robotic-assisted surgery in non-obese and obese patients.
Methods and Procedures: A retrospective review of 331 consecutive planned procedures
performed by a colorectal surgery group at a single academic institution using the da Vinci
robotic system between October 2009 and July 2015 was performed. Patients were divided
into non-obese (BMI \ 30 kg/m2) and obese (BMI C 30 kg/m2) groups, and were clinically matched by gender, age, and procedure. Intraoperative and postoperative
complications, operative time, estimated blood loss, and length of stay were examined.
Comparison of means between groups were analyzed using a two-tailed students t-test, and
a two-tailed Fishers exact test was used to evaluate the number of specific complications
and conversions to laparotomy between groups.
Results: Following case matching, each group included 108 patients comprised of 50 men
and 58 women. Patient demographics did not differ except for a mean BMI of 24.6 3.15
and 36.2 5.67 kg/m2 (p \ 0.0001). Surgeries included low anterior resection (N = 60),
right colectomy (N = 60), sigmoid colectomy (N = 38), left colectomy (N = 30), excision
of rectal endometriosis (N = 6), total proctocolectomy (N = 4), abdominal pernineal
resection (N = 4), subtotal colectomy (N = 4), ileocecectomy (N = 2), proctectomy
(N = 2), rectopexy N = 2), transanal excision of rectal mass (N = 2), and colostomy site
hernia repair (N = 2). Mean operative time (272.69 115.43 vs 282.42 120.51 min;
p = 0.55), estimated blood loss (195.23 230.37 vs 289.19 509.27 mL; p = 0.08), and
length of stay (5.38 4.94 vs 4.56 4.04 days; p = 0.18) did not differ between groups.
There was no difference in overall complications between non-obese and obese patients (20
vs 27; p = 0.30). However, when evaluating specific complications, obese patients had a
higher prevalence of wound complications (9.3 % vs 1.9 %; p = 0.03). After stratifying
groups by abdominal and pelvic surgeries, obese patients undergoing abdominal colon
surgery had a higher prevalence of complications (30.9 % vs 14.7 %; p = 0.04) with
71.4 % involving wound complications.
Conclusion: Laparoscopic colorectal surgery has been associated with increased laparotomy and complication rates in obese patients. However, robotic-assisted surgery may
minimize conversion to laparotomy and complications due to improved 3-D visualization,
wristed instrumentation, and surgeon ergonomics. Despite this, wound complications
continue to have a higher prevalence in obese patients.

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P654

19962016: 20 Years of Robotic Surgery in MexicoThe

Experience At Our Hospital

Robot-Assisted Choledochotomy and Common Bile Duct

Exploration as an Option for Complex Choledocholithiasis

Harry S Miller, MD1, Jonathan M Sackier, MD2, 1H.G.R. 20 Instituto

Mexicano del Seguro Social, 2Oxford University Nuffield Department
of Surgical Sciences

Ahmed Almamar, MD, MSc, FRCSC, Heather Emmerton-Coughlin,

MD, FRCSC, Nawar Alkhamesi, MD, PhD, FRCS, Gen, Surg, FRCS,
FRCSEd, Christopher M Schlachta, BSc, MDCM, FRCSC, FACS,
Department of Surgery, Western University and Canadian Surgical
Technologies and Advanced Robotics (CSTAR), London, Canada

Introduction: In August 1993, in San Diego, Ca., the first robotic arm system for holding
the laparoscope was used by Sackier, M.D. called Automated Endoscopic System for
Optimal Positioning (AESOP). In our Hospital in Tijuana, Mexico, on June 26, 1996 the
first two cases of robotically assisted cholecystectomies with AESOP 1000 where performed. On November 1999 the tele robotic system Zeus was at our Hospital and dry lab
was set, and porcine lap cholecystectomies where performed. From 1999 to 2015, 09
robotic courses have taken place, one of them endorsed by SAGES, the last eight with
AESOP 3000 voice activated.
Methods: 173 robotically assisted cases have been performed with AESOP (Automated
Endoscopic System for Optimal Positioning) the first 20 with AESOP 1000 (pedal and hand
controlled) and 6 degrees of freedom, with AESOP 3000 with voice activation and 7
degrees of freedom 153 cases have been performed.. During the 9 courses all surgeons have
demonstrated to be competent after 2 weeks of training.. All cases had informed consent
and full explanation of the procedure by the surgical team.
Results: In 1996 20 cases performed with AESOP 1000, 14 cholecystectomies, 03 TEP
Hernia repairs, 01 tubal ligation and 2 Nissen fundoplications. From 1999 to 2015 a total of
153 cases have been performed during 9 courses each one two weeks in length 01 liver
biopsy, 01 TAPP Hernia repair, 12 Nissen fundoplications, 01 diagnostics for gunshot
wound and bullet extraction, 01 gastro- plicate 01 gastric sleeve this to for obesity control,
and 136 laparoscopic cholecystectomies several of them including cholangiography. No
serious complications have been present in all cases, surgical times similar to hand
laparoscope control. Quality of image and stillness better with Robot enhancement.
Conclusions: Using a Robotic Scope Holder with voice activation facilitates several basic
laparoscopic procedures even some with higher technical dificulty like intracorporial
knotting and dissections. In the 09 courses or Minifellows, the best area for training is the
cholecystectomy because it is the most frequent procedure performed. The system even out
dated is a great area for training skills and it is cost-efficient. Not mentioned in this abstract,
Mexico is participating in the robotic era with new and more robust systems with magnified
enhancement and dexterity.

P653
Potential Advantages of Robot-Assisted Gastrectomy Over
Laparoscopy-Assisted Gastrectomy Regarding
Lymphadenectomy in Gastric Cancer
Kecheng Zhang, Hongqing Xi, Jianxin Cui, Shibo Bian, Liangang
Ma, Jiyang Li, Bo Wei, Lin Chen, Department of General Surgery,
Chinese Peoples Liberation Army of General Hospital
Purpose: Previously we have performed retrospective analysis to compare robot-assisted
gastrectomy (RAG) with laparoscopy-assisted gastrectomy in short-term surgical outcomes,
and have demonstrated the feasibility and safety of robotic surgery for gastrectomy. In
present study, we conducted prospective and comparative analysis to investigate the ability
of RAG versus LAG to remove lymph nodes in technically demanding areas.
Methods: Between August 2014 and August 2015, sixty-one patients who underwent RAG
and 235 patients who underwent LAG were enrolled in this study. Clinical characteristics,
operative parameters, pathological and oncological data were collected prospectively and
numbers of retrieved lymph nodes for each station were analyzed according to the extent of
surgery.
Results: Days of first flatus were 4.6 1.1 days for RAG and 4.4 0.9 days for LAG
(P = 0.142). Days of eating diet were 5.3 3.7 days for RAG and 5.8 4.1 days for
LAG (P = 0.388). There were similar intraoperative blood transfusion rate (P = 0.617),
postoperative hospital days (P = 0.071), proximal resection margin (P = 0.064) and distal
resection margin (P = 0.667) between the two groups. Numbers of postoperative complications were also similar between the robotic and laparoscopic groups (P = 0.854).
However, robotic surgery had less severity of complications when complications were
graded according to the Clavien-Dindo classification (P = 0.039). More numbers of lymph
nodes were retrieved in the RAG group than that of LAG group (P = 0.046). Similarly, the
RAG group had more retrieved lymph nodes in N2 area (P = 0.038). In patients who
underwent distal gastrectomy, the numbers of retrieved lymph nodes around splenic artery
area were 2.8 1.7 and 2.2 1.2 for RAG and LAG respectively (P = 0.036). In patients
who underwent total gastrectomy, 2.8 1.2 and 2.1 1.0 lymph nodes were retrieved for
RAG and LAG around splenic artery area (P = 0.049). In addition, 1.8 0.8 and
1.3 0.7 lymph nodes were retrieved around splenic hilum (P = 0.042).
Conclusion: Our study demonstrates that RAG has advantages over LAG regarding lymph
nodes dissection in technically demanding area and might contribute to radical D2 lymphadenectomy with less severity of complications.

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Background: The aim of this study is to evaluate the safety and feasibility of elective,
robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) as compared to the open technique for ERCP refractory choledocholithiasis.
Method: A prospective database of all RCD/CBDE has been maintained since our first
procedure in 2006. With ethics board approval, this database was compared with a detailed
chart-review of all contemporaneous elective open procedures (OCD/CBDE) performed
from 2005 until present. Emergency procedures were excluded from analysis. Outcomes
were analyzed on the basis of intent-to-treat.
Results: In the past decade, a total of 67 cases of elective CD/CBDE were performed in our
institution, comprising 40 consecutive, unselected RCD/CBDE performed by one surgeon
and 27 OCD/CBDE performed by others. Comparing RCD/CBDE to OCD/CBDE there
were no significant differences between groups with respect to age (65 20 vs. 67 18,
p = 0.05), gender (M12:F28 vs. M16:F25, p = 0.05), ASA class, co-morbidities or reason
for failed ERCP. Patients had prior cholecystectomy in 38 % of those undergoing RCD/
CBDE compared to 33 % having OCD/CBDE. The mean duration of surgery for RCD/
CBDE was 31 minutes longer than OCD/CBDE (205 70 min vs. 174 73 min,
p = 0.02), while the median hospital stay was six days less (4 vs 10 days, p = 0.02). Four
had outpatient RCD/CBDE. Postoperative complications, mainly wound complications
(54 %), occurred in 9 (22 %) RCD/CBDE and in 15 (56 %) OCD/CBDE (p = 0.39).
Conversion to laparotomy was performed in 6 (15 %) patients, mainly due to adhesions,
and was associated with a higher complication rate than non-converted cases (67 % vs.
15 %, p = 0.02). There was one mortality in the RCD/CBDE group and two in the OCD/
CBDE group. External biliary drainage (t-tube) was used in 52 % of patients of roboticassisted group compared to 77 % in the open group (p = 0.37).
Conclusion: The use of robotic-assisted CD/CBDE trades longer operating time for a
significant reduction in hospital stay. A trend toward reduced postoperative complications
was not statistically significant. A cost-effectiveness analysis is in progress.

P655
Need Help with Port-Placement in Robot-Assisted Surgery:
A Survey Study
Jinling Wang, PhD, Katherine S Lin, MD, Keith A Watson, MD,
Michael L Galloway, DO, Minia Hellan, MD, Caroline G.L. Cao,
PhD, Wright State University
Introduction: Robot-assisted laparoscopic surgery has been widely adopted and the
number of procedures done with the da Vinci Surgical System is growing rapidly.
Although the advantages of robot-assisted surgery over traditional laparoscopic surgery are
obvious, there are several limitations of robot-assisted surgery such as higher costs, and
longer setup time. One of the critical steps in setting up the robotic system is port-placement, in which the locations of the ports are selected to ensure adequate visualization of the
surgical site, avoid external arm collision, and provide maximal instrument reach. The
purpose of this study was to identify the key factors influencing the performance of the portplacement task in robot-assisted surgery, and gather domain expert input about the design of
enabling technology for this important task.
Methods and Procedures: An 18-item questionnaire was handed out at the Society of
American Gastrointestinal and Endoscopic Surgeons (SAGES) 2015 Annual Meeting and at
Miami Valley Hospital in Dayton, OH. Participants had the option to fill out the questionnaire online through Qualtrics (online survey software). Twenty-three hardcopy
questionnaires were returned. Sixty-four questionnaires were submitted online but only 22
were complete a completion rate of 34 %. In total, 45 questionnaires were analyzed. 42 %
of the questionnaires were from attending surgeons and 58 % from residents.
Results: 47 % of the participants listed port-placement as the most challenging task in
using the robotic system, followed by learning to use the robotic system (21 %), setup
(14 %), team work (14 %), and lack of tactile feedback (4 %). The results showed that in
the past 3 years, 36 % of the attending surgeons and 61 % of the residents were involved in
a case where the robotic approach was abandoned or convert due to poorly placed ports.
Both attending surgeons (53 %) and residents (53 %) had to work harder at a case due to
the poorly placed ports in the last 3 years. Fifty-nine percent (59 %) of the participants
listed choosing port locations as the most challenging part in the port-placement task.
Patients body habitus and previous surgery history were the key patient characteristics that
could cause difficulty for the port-placement task.
Conclusion: Results confirmed that port placement is a challenging task in using the
robotic system. There is overwhelming support from the surgeons surveyed to develop
assistive technology for this important task. Therefore, our next step will be to develop a
patient-specific port-placement decision aid for robot-assisted laparoscopic surgery.

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P657

Robotic Versus Laparoscopic Distal Pancreatectomy: A Metaanalysis of Short-Term Outcomes

Robot Single-Site Cholecystectomy: Early Experience of First 1

Year

Jia-Yu Zhou, MD1, Yi-Ping Mou, MD, FACS2, Xiao-Wu Xu, MD2,
Yu-Cheng Zhou, MS2, Chao Lu, MS1, Rong-Gao Chen, MS1,
1
Zhejiang University, 2Zhejiang Provincial People Hospital

Jae Hoon Lee, Ki Byung Song, Dae Wook Hwang, Song Cheol Kim,
Kwang-Min Park, Young-Joo Lee, Asan Medical Center, Seoul,
Korea

Aim: To compare the safety and efficacy of robotic-assisted distal pancreatectomy (RADP)
and laparoscopic distal pancreatectomy (LDP).
Methods: A literature search of PubMed, EMBASE, and the Cochrane Library database up
to June 30, 2015 was performed. The following key words were used: pancreas, distal
pancreatectomy, pancreatic, laparoscopic, laparoscopy, robotic, and robotic-assisted. Fixed
and random effects models were applied. Study quality was assessed using the NewcastleOttawa Scale.
Results: Seven non-randomized controlled trials involving 568 patients met the inclusion
criteria. Compared with LDP, RADP was associated with longer operating time, lower
estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay. There was
no significant difference in transfusion, conversion to open surgery, overall complications,
severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and
30-day mortality between the two groups.
Conclusion: RADP is a safe and feasible alternative to LDP with regard to short-term
outcomes. Further studies on the long-term outcomes of these surgical techniques are
required.

Minimally invasive approaches for cholecystectomy are evolving in a surge for the best
possible clinical outcome for the patients. A robotic set of instrumentation to be used with
the da Vinci Si Surgical System has been developed to overcome some of the technical
challenges of manual single incision laparoscopy.
From August 2014 to March 2015, all consecutive robotic single-site cholecystectomies
(RSSC) were prospectively collected in a dedicated database. Demographic, intra- and
postoperative data of all patients that underwent RSSC at Asan Medical Center (Seoul,
Korea) were analyzed.
During 12 months, 120 patients (83 women, 37 men) underwent RSSC at our institution.
The operations were performed by 5 experienced hepatobiliary surgeons. The dominating
preoperative diagnosis was cholelithiasis. Average patients age was 42.1 years (range,
1764), and average body mass index was 23.8 kg/m2 (range, 1737). The mean robot
docking time was 5.8 2.4 min (range, 320), and surgeon console time was
18.4 12.2 min (range, 565). The mean overall operative time (skin-to-skin) was
48.8 16.7 min (range, 25105). Completion of RSSC was done in 119 patients. One
patient with conversion to conventional laparoscopy due to severe inflammation with dense
adhesion was observed, and final diagnosis of this patient was xanthogranulomatous
cholecystitis. Except one case of laparoscopic conversion, no cases required traction suture,
additional robotic arm, conversion to open or drain. Intraoperative blood loss was negligible. There were no collisions between the robotic arms and no other robot-related
problems. Average postoperative length of stay was 1.7 day (range 14). There were no
immediate postoperative complications (bleeding, bile leak, strictures, or wound dehiscence). The mean Numerical Rating Scale score 6 hours after the operation was 2.9 1.2
(range, 17). After discharge, two patients had a superficial wound infection that was
treated with a course of dressing, and resolved without any further consequence. In followup of all patients, there were no biliary leaks, no bile duct or hepatic artery injury, and other
inadvertent injuries to the surrounding structures.
RSSC is feasible and safe and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy.

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P658
Long-Term Result of Hybrid-Type Endoscopic Thyroidectomy
(HET) For Differentiated Thyroid Carcinoma Including Novel
Single-Incision Endoscopic Thyroidectomy (SIET) To Testify
Curability
Masayuki Tori, MD, PhD1, Katsuhide Yoshidome, MD, PhD1,
Toshirou Shimo, MD, PhD1, Kana Anno, MD1, Hiroki Akamatsu,
MD, PhD2, Masahiro Tanemura, MD, PhD2, Kentarou Kishi, MD,
PhD2, Mitsuyoshi Tei, MD, PhD2, Toru Masuzawa, MD, PhD2,
Masaki Wakasugi, MD2, Youzou Suzuki, MD, PhD2, Kenta
Furukawa, MD, PhD2, Toshiki Takahashi, MD, PhD3, 1Endocrine
surgery, Osaka Police Hospital, 2Digestive surgery, 3Cardiovascular
surgery

Fig. 2 .

Background and Aim: Pure endoscopic thyroidectomy (ET) for differentiated thyroid cancer (DTC) could not be standardized because of
incompatibility to enough lymph node dissection and invasive cases including invasion to the trachea. To overcome these important issue, we
already developed hybrid-type endoscopic thyroidectomy (HET: Toris method; Surg Endosc 2014), combining ET and small skin incision surgery.
As further step, we have developed single-incision endoscopic thyroidectomy (SIET) for thyroid carcinoma. To examine curability, we present longterm result of HET (including SIET) comparing with traditional thyroid surgery for carcinoma.
Patients and Methods: For the past 7 years, total number of DTC was 754 which were performed thyroidectomy (total and lobectomy with lymph
node dissection). Among them, HET was performed for 323 ceases (SIET for 35 patients who chosed). As to the operative indication for HET, tumor
size is\4 cm, with or without tracheal invasion needing shaving. These 754 cases were clinically examined retrospectively. Evaluation of cosmetics
and pain scale were added to the results. (Op procedures of SIET) Single small color incision (1.52.0 cm) is made just above the clavicle of the
tumor side, both in lobectomy and total thyroidectomy. Before SIET port is attached to the incision, central lymph node dissection is performed. To
obtain enough working space, anterior neck muscles are divided longitudinally at the midline, and after dissection of the space between thyroid and
the muscles, both side of the anterior muscles are pulled toward each side supported by L-shaped steel lift fixed to the edge of the operating table.
Three 5 mm trocars are inserted on the SILS port. By using some useful retractors, recurrent nerve and parathyroids are clearly visible, and finally
lobectomy or total thyroidectomy can be done. Result: All of the operative cases are alive. As to the recurrence and metastasis, only 2 cases had LN
metastasis and reoperation was performed, in HET group (average follow-up 39 months), on the other hand, 3 cases suffered from LN metastasis, 2
cases recurrence in the residual lobe, and 2 cases lung metastasis in the traditional op group (average follow-up 42 months).
Conclusion: Our findings support the idea that HET (including SIET) is a feasible, practical, and safe procedure, with excellent cosmetic benefits as
well as curability.

P659
Robotic Resection of a Pancreatic Tail Tumor Resulting
in an Intrapancreatic Accessory Spleen

Fig. 3 .

Alexander Ramirez, MD, Wade G Douglas, MD, FACS, Tallahassee

Memorial HealthCare, Florida State University College of Medicine
Introduction: Accessory spleen has been reported in about 30 % of autopsy studies (1) and until 65 % of patients after splenectomy (2). The tail of
the pancreas is the second most common location of accessory spleen (1). It is very important to identify the intrapancreatic accessory spleen without
invasive diagnostic tests because there are few real indications for surgical resection (3). Intrapancreatic accessory spleen has rarely been noted
radiologically before surgery and when there is concern about the differential diagnosis, especially with very high vascular tumors, surgical resection
is indicated.
Case Report: We presented a case of a 33 year-old male with a history of recent cholecystectomy that developed nausea and vomiting a few days
after being discharged from the hospital. He was seen in the Emergency Room for these symptoms and a CT scan of the abdomen and pelvis revealed
a 2.9 cm solid tumor in the tail of the pancreas (Figs. 1, 2). The patient denied fatigue, diarrhea, hypoglycemic or syncopal episodes. All the
endocrine markers were negative and the patient was scheduled for a robotic distal pancreatectomy and splenectomy.
The procedure was done robotically and during the procedure we used the laparoscopic ultrasound probe to identify the location of the pancreatic
mass (Fig. 3) and to confirm the total resection after the distal pancreatectomy was performed (Fig. 4). The patient had an uneventful post operative
period and was discharged home in the post operative day 2 in stable condition. The pathology report shows a 2.5 9 2 9 2 cm accessory spleen
involving the parenchyma of the tail of the pancreas (Fig. 5).
Conclusion: Intrapancreatic accessory spleens can radiographically mimic a malignant process. Surgery with pathology evaluation of the specimen
is the only reliable means of diagnosis. This surgical procedure can be done laparoscopically or robotically in a safe way. While intrapancreatic
accessory spleen is a very rare condition, it is an important component of a complete differential diagnosis for a patient presenting with a pancreatic
tail tumor.
References
1. Halpert B, Gyorkey F. Lesions observed in accessory spleens of 311 patients. Am J Clin Pathol.1959;32:165168.
2. Eraklis AJ, Filler RM. Splenectomy in childhood: a review of 1413 cases. J Pediatr Surg.?1972;7:382388.
3. Kurmann A, Michel J, Stauffer E. Egger B. Intrapancreatic Accessory Spleen Misdiagnosed as a Nonsecreting Endocrine Tumor: Case Report and
Review of the Literature. Case Rep Gastroenterol. 2010 May-Aug; 4(2): 210214.

Fig. 4 .

Fig. 1 .
Fig. 5 .

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P662

Concepts and Techniques in Laparoscopic Splenectomy

Retroperitoneal Bronchogenic Cyst: Case Report and Review

of Literature

M Ishida, MD, PhD, T Morikawa, MD, PhD, T Aoki, MD, PhD, K

Ariake, MD, PhD, S Maeda, MD, PhD, K Masuda, MD, PhD, K
Fukase, MD, PhD, H Ohtsuka, MD, PhD, M Mizuma, MD, PhD, N
Sakata, MD, PhD, K Nakagawa, MD, PhD, H Hayashi, MD, PhD, F
Motoi, MD, PhD, T Naitoh, MD, PhD, M Unno, MD, PhD,
Department of Surgery, Tohoku University, Graduate School
of Medicine
Introduction: Laparoscopic splenectomy (LS) is applied to various diseases such as splenic
tumor, liver cirrhosis, and idiopathic thrombocytopenic purpura (ITP) for treatment and to
homological diseases for diagnosis. Thanks to its low-invasiveness and cosmetic superiority, most splenectomy is now performed under laparoscopy.
Although LS seems easy and simple, there are some concepts and techniques which are
common with open splenectomy and which are new to laparoscopy. Those concepts and
techniques should be understood well to make LS right and accurate.
We introduce and validate 3 techniques (described in methods section) adopted in our
institute to perform LS safely and efficiently.
Methods and Procedures: The recent five cases of LS performed in our institute in 2015
were analyzed.
For every LS, LeGEART (left gastroepiploic artery retraction technique) was adopted for
lysis of adhesion between the spleen and the retroperitoneum. LeGEART is that by holding
the trunk of the left gastroepiploic artery and vein up, the splenic hilum is elevated.
For ITP, the left half of the greater omentum was excised to remove latent accessory spleen,
because the accessory spleen might become the cause of ITP after splenectomy.
For the cases of splenomegaly, the splenic artery was ligated at early time of operation for
the purpose of shrinking the spleen for better handling and reducing blood loss by stopping
the blood inflow to the spleen.
Results: There were two ITP cases and three suspected cases of malignant lymphoma, and
two cases of splenomegaly.
Using LeGEART, the lysis of the adhesion between the spleen and the retroperitoneum was
eased up.
For all ITP cases, the left half of the greater omentum was excised. However, no accessory
spleen was found in the excised greater omentum. And no adverse effect was caused by the
excision of the left omentum.
The splenic artery was ligated at the early period of LS in the cases of splenomegaly. In a
case, the size of the spleen turned smaller after the ligation (9 cm to 6.5 cm). That made it
easy to handle the spleen.
Conclusion: The three techniques in LS were efficient ant rational. Although the surgical
procedure of LS is relatively simple compared to resection of other organs, we need to
consider the order of the procedures, the extent of resection of the omentum, and the
technique for lysis depend on the disease and the condition of the spleen in LS.

P661
Minimally Invasive AdrenalectomyChoosing the Appropriate
Approach for the Patient

Ashish Padnani, MD, Rashmi Bawa, MD, Darshak Shah, MD, James
Satterfield, MD, New York Presbyterian Queens
Background: Bronchogenic cysts (BC) are developmental anomalies derived from foregut,
most commonly found in mediastinum but rarely in retroperitoneum. Very few cases have
been reported in the literature. Most BCs are asymptomatic and are identified incidentally
during imaging done for unrelated reasons. Surgical exploration is recommended. Very few
cases of laparoscopic resection of the cyst have been reported.
Case Presentation: We present a case of 73 year old female patient who was found to have
left retroperitoneal cyst on MRI during workup for chronic flank pain. Patient underwent
Endoscopic Ultrasound (EUS) as further work up to further define the lesion. Laparoscopic
fenestration of the cyst was performed. Pathology showed benign bronchial-type epithelial
cells with focal adrenal tissue.
Conclusion: Bronchogenic cysts are extremely uncommon anomalies that are mostly
asymptomatic and diagnosed on imaging studies done for unrelated reasons. Most of these
are benign cysts. Surgical exploration is recommended. Laparoscopic fenestration is safe
and feasible management approach.

P663
Comparative Analysis of Laparoscopic Adrenalectomy in a High
Volume Center Compared to ACS-NSQIP
Karly Lorbeer, Arghavan Salles, MD, PhD, Bruce L Hall, MD, PhD,
Yan Yan, PhD, L. Michael Brunt, MD, Washington University
Introduction: Laparoscopic adrenalectomy is a complex operation requiring advanced
surgical skills. However, most adrenalectomies in the US are done outside of high volume
(HV) centers. We sought to evaluate whether outcomes for laparoscopic adrenalectomy
vary at a HV center compared to centers in the ACS-National Surgical Quality Improvement Program (ACS-NSQIP).
Methods and Procedures: Data for all adrenalectomies at the HV center from 20012012
were compared to cases from the ACS-NSQIP 20052011 database with a CPT code for
laparoscopic or open adrenalectomy and an ICD-9 code for adrenal gland pathology. Data
were analyzed using univariate and multivariate regression analyses.
Results: As shown in the table, patients in the ACS-NSQIP database were slightly older and
had a slightly higher BMI and ASA class than those at the HV center. A greater proportion
of cases were performed laparoscopically at the HV center compared to ACS-NSQIP. For
laparoscopic cases, patients at the HV center had lower rates of ACS-NSQIP-defined
complications compared to patients in the ACS-NSQIP database overall. When we included
additional locally-tracked complications such as adrenal insufficiency and retroperitoneal
hematoma, the complication rate at the HV center was 8.5 %. The rate of conversion to
open at the HV center was 4.2 % but was not reported in the ACS-NSQIP database.
Multivariable regression analysis showed that only higher intraoperative blood loss (OR
1.003) and longer postoperative length of stay (OR 1.358) were associated with increased
complications in the HV group whereas age, BMI, operative time and postoperative lengthof-stay were associated with more complications in the ACS-NSQIP group (p \ 0.01).

Ariel Schweitzer, MD, Ibrahim Matter, MD, Gideon Sroka, Bnai-Zion

Medical Center
Background: minimally invasive adrenalectomy can be performed either by the laparoscopic (LA) or the retroperitoneoscopic (PRA) approaches. Both have been shown to be
safe and effective. Nevertheless, there are no clear guidelines to choose a better approach
for a specific patient. The purpose of this study was to assist in defining the indications for
each approach.
Methods: A retrospective analysis of all patients who went through adrenalectomy in our
department, between January 2012 and August 2015. Imaging, perioperative, and pathological parameters, were compared between the different approaches. Data is presented as
mean SD.
Results: LA was performed in 29 patients with 31 tumors, PRA in 16 with 18 tumors and 1
patients was operated in open approach. Size of the lesions was 53 23 mm (LA),
28 9 mm (PRA), and 135 mm (open). Blood loss was negligible in PRA. Length of stay
(LOS) was 5.2 4.7, 2.9 1.6, and 8 days respectively. There were no major
complications.
Conclusion: Patients with benign appearing tumors of\5 cm would benefit from PRA, and
more so if theyve had previous upper abdominal surgery, or if they need bilateral intervention. In patients with tumors [10 cm with high suspicion for malignancy the open
approach should be strongly considered. The rest of the lesions should be resected
laparoscopically.

Conclusion: Patients at the HV center had lower rates of ACS-NSQIP-defined complications than those in the ACS-NSQIP database and had higher rates of completely
laparoscopic procedures. This suggests that laparoscopic adrenalectomy may be underutilized nationally. In addition, ACS-NSQIP should consider including important determinants
of outcome such as adrenalectomy-specific complications (e.g., adrenal insufficiency) and
intraoperative blood loss.

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P664
Laparoscopic Management of Giant Cystic Feocromocytoma.
Rare Case in IV Level Clinic in Colombia
Evelyn Dorado, FUNDACION VALLE DEL LILI
Introduction: Adrenal cysts are rare, its incidence is from 0.064 to 0.18 %. Although most
non-functioning adrenal cysts are asymptomatic, they can reach sufficient size to produce
nonspecific abdominal symptoms, back pain or hypertension. pheochromocytomas are
hipervascularizadasque lesions in 90 % of cases, produce hypertension. Usually reported as
solid lesions, due to its hypervascularization, they may have areas with focal or partial
cystic degeneration.
Main: To describe the case of a patient with cystic pheochromocytoma which was given
laparoscopic management

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Surg Endosc (2016) 30:S325S500

Methods: Female patient of 59 years that started 2 years ago by weight loss studies, made
tomography and abut a mixed 6 9 5 9 5 cm right adrenal incidentaloma. Relizan which
metanephrines are elevated, aldosterone renin normally. That is to run in conjunction with
endocrinology, alfabloqueo starts and is scheduled for laparoscopic adrenalectomy. At the
time taking two antihypertensive with difficult control of blood pressure
Results: four-port technique in left lateral decubitus, a mass with a cystic component of
95 % of 6X7 cm is observed. during surgery the patient presented mean arterial pressures
of 180 and 200 were controlled by anesthesiology after clipar adrenal vein tendency to
hypotension. He was transferred to ICU. 1 day stay in ICU after 1 day on the floor and
discharged with half the dose of antihypertensive
Pathology: pheochromocytoma, positive markers: chromogranin siaptofisina, NSE, S-100,
vimentin. Metanephrines at 4 weeks of negative surgery
Conclusion: ystic pheochromocytomas are uncommon injuries that have specific imaging
characteristics that associated with clinical and laboratory data allowed to board a diagnosis. The treatment is surgical, and laparoscopy offers a very good alternative in terms of
patient recovery.